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I LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA 






MANUAL 



Clinical Diagnosis 



Dr. OTTO SEIFERT and Dr. FRIEDRICH MULLER 

PRIVATDOCENT IN WURZBURG ASSISTENT DER II. MED. KLINIK IN BERLIN 



TRANSLATED FROM THE FIFTH GERMAN EDITION, ENLARGED AND REVISED, WITH 
THE PERMISSION OF THE AUTHORS, BY 

WILLIAM BUCKINGHAM CANFIELD, A.M., M.D. (Berlin) 

Fellow of the American Academy of Medicine ; Member of the Medical and Chirurgical 

Faculty of Maryland ; Visiting Physician to the Union Protestant Infirmary 

of Baltimore; Lecturer on Clinical Medicine, and Chief 

of Chest Clinic, University of Maryland. 



?3 



SECOND ENGLISH EDITION REVISED AND ENLARGED 

WITH FIFTY ILLUSTRATIONS AND ONE COLORED 1'LATK 




z 



c 



G. P. PUTNAM'S SONS 

NEW YORK LONDON 

27 WEST TWENTY-THIRD ST. 27 KING WILLIAM ST., STRAND 

S^e IttHtkerbochcr. |jtt*s 
1890 



^,-C/v 
.£**> 



COPYRIGHT. 

G. P. PUTNAM'S SONS 



Press of 
G. P. Putnam's Sons 

New York 



n 



TO HIS ESTEEMED FRIEND 

PROFESSOR PI. KNAPP 

THIS WORK IS DEDICATED BY 
THE TRANSLATOR 



PREFACE TO THE FIRST EDITION. 



The presentation of this manual to the public is due to 
the encouragement of our highly esteemed teacher and 
chef, Geheimrath Professor Gerhardt. We have endeav- 
ored to supply a want by giving in an epitomized form, 
the different methods of examination, as well as a con- 
venient collection of those data and figures which should 
always be familiar to the physician and student. These 
data, on account of their number and variety, cannot be 
remembered with the necessary exactness, and, on the 
other hand, are so scattered throughout numberless text- 
books and monographs, that it would be troublesome and 
time-wasting to search for them. In selecting and ar- 
ranging this material, we have been led by the experience 
gained in holding courses, and we have also endeavored 
to consider the practical needs of the student and physi- 
cian by noting only what is reliable, and omitting every 
thing self-evident and of secondary importance. 

THE AUTHORS. 

Wurzburg and Berlin, April, 1886. 



PREFACE TO THE THIRD EDITION. 



In preparing the third edition of this manual, I have 
endeavored to do justice to all the wishes expressed by the 
different critics, as well as to consider any wants which 
have become apparent since the last edition. Conse- 
quently, a number of improvements and additions have 
been made, and among them it seemed necessary to add 
some new illustrations, especially to the chapters on 
blood and urine. The illustrations of the leucocytes are 
from preparations of Professor Ehrlich, and those of the 
urinary sediment are, in part, taken from the physico- 
chemical atlas of Funke. The tables in the last chapter 
are intended to make the questions of diet and assimila- 
tion of practical use in the sick-room. In conclusion, I 
should like to thank all those gentlemen who have so 
kindly assisted us by their suggestions. 

Berlin, October, 1886. 



TRANSLATOR'S PREFACE. 



The favor with which this book has been received in 
Germany, and its eminently practical and concise man- 
ner of dealing with the different important points in diag- 
nosis, seem to justify its translation into English. It has 
been brought down to the latest acquisitions of science, 
thus representing the most advanced views. For the 
sake of clearness, the figures relating to weight, measure, 
length, etc., as well as the dose table at the end of the 
book, have been modified to conform to the system used 
in America and England. Translations from the original 
into French and Russian are now in press. 

The translator takes great pleasure in thanking in this 
place his friend Dr. Robert T, Wilson, for kind services 
and valuable suggestions rendered in the proof-reading 
and correction. 

W. B. C. 

ioio North Charles St., Baltimore,- 
September, 1887. 



TRANSLATOR'S PREFACE TO THE SECOND 
ENGLISH EDITION. 



The exhaustion of the first edition and the changes in 
the original call for a revision of this translation. The 
principal changes are certain additions in diseases of 
the heart and lungs, an entire revision of the ever- 
changing section on bacteriology, the correction of 
certain errors kindly pointed out by critics, and the 
addition of a handsomely executed chromo-lithograph 
of the micro-organisms. 

W. B. C. 

ioio North Charles St., Baltimore. 
November, 1890. 



CONTENTS. 



PAGE 

Preface to First Edition v 

Preface to Third Edition vi 

Translator's Preface vii 

Chap. I. — The Blood i 

Chap. II. — The Temperature S 

Measles 10 

Scarlet-Fever ......... io 

Small-Pox ii 

Varioloid . . . . . . . . .11 

Chicken-Pox ......... 12 

Typhoid Fever ........ 12 

Typhus Fever 13 

Relapsing Fever ........ 13 

Malaria .......... 14 

Erysipelas . ........ 15 

Pneumonia Crouposa . . . . . . .15 

Chap. III. — Organs of Respiration 16 

Topography of the Chest . . . . . . .16 

Spirometry ......... 20 

Percussion of the Thorax . . . . . . .21 

The Normal Boundaries of the Lung . . . .21 

Topography of the Different Lobes of the Lung . . 22 

Auscultation ......... 27 

The Breathing Sound ....... 27 

Rales .28 

Auscultation of the Voice . . ... 29 

Chap. IV. — The Sputum 32 

Morphological Constituents ...... 34 

•Chap. V. — -Laryngoscopy and Rhinoscopy .. . - 37 

Voice .......... 37 

The Muscles of the Larynx ...... 38 

ix 



CONTENTS. 



Nerves of the Larynx . 
Paralysis of the Vocal Cords 
Chap. VI. — Circulatory System 
Inspection and Palpation 
Percussion of the Heart . 
Auscultation of the Heart 
The Heart Murmurs 
Auscultation of the Blood-Vessels 
Chap. VII.— The Pulse 
Chap. VIII. — Digestive and Abdominal Organ 
The Teeth ..... 

The Saliva . 

(Esophagus ..... 

Stomach ...... 

Examination of the Stomach's Contents 
Liver ...... 

The Spleen . . 

Abdomen ..... 

The Faeces 

Chap. IX. — The Urine-Producing System 
The Genito-Urinary Organs 
The Urine ..... 
Normal Constituents of the Urine 
Inorganic Constituents of the Urine 
Pathological Constituents of the Urine 
Organic Sediments 
Chap. X. — Transudations and Exudations 
Chap. XL — Parasites .... 
i. animal parasites : 

Cestodes — Tape-Worms 
Nematodes — Round-Worms 
Trematodes — Flat-Worms 
Arthropodes .... 
Protozoa ..... 
ii. vegetable parasites : 

Hyphomycetes .... 
Yeast Fungi .... 
Schizomycetes or Bacteria 



PAGE 

38 
39 
41 
41 

43 
45 
46 

48 
50 
55 
55 
56 
56 
57 
58 
60 
6 1 
62 
63 
67 
67 
67 
70 

74 

77 
89 

91 
96 

96 

98 

100 

100 

101 

101 
102 
102 



CONTENTS. 



XI 



Chap. XI. — The Nervous System 
Testing the Sensibility 
Testing the Motility 

Motor Symptoms of Irritation 
Diagnosis by Means of Electricity 
Reflexes ...... 

The Most Important Clinical Points 
the Nervous System . 
Brain and Spinal Cord . 
Cranial Nerves .... 

Spinal Nerves . 
Chap. XIII. — Analysis of the Pathologicai 

ments 

Urinary Concrements .... 
Concrements of the Intestine . 

Salivary Calculi 

Gall Stones 

Chap. XIV. — Metabolism and Nutrition 

Table of the Weights of the Human Body 
Dose Table ....... 

Appendix ....... 

Index ........ 



the Anatomy 



Concre 



PAGE 

10S 
1 08 
in 
112 

113 
121 

124 
124 
127 
129 

132 
132 
134 
134 
134 
136 

143 
144 
163 
175 



Fie. 1 



Fig. 2 




-> ^ 



J *t 



l v w *~ J v. 



r , 



Pneumonococcus 



Bacillus Cholera 



Fig. 3 



Fig.* 



V 






X 7/ ^ 
\ 

BacStus Anthracis 



<\r*J 



SpirHhurv Obermeiri 



Fig. 5 



• ••• .f ' • :*•*• 

.• : " % •* . * 



Fig. 6 



-.■ . 



StapTiflo coccus pyogenes aureus 



Streptococcus Brysipelatos 



Prmted TnrJF.Ba'(/marm. .Wiesbaden . 



Pig. 7 






** if 



PflTi"^ 






* >» ^ 



Bacillus Tuberculosis 



Fig. 



Fig. 9 







Bacillus Leprae 



Bacillus Eqvimae 



Fig. 10 



% 



***** 



Fig. 11 




Bacillus Typhosus 



LiLh . CJSrst Leipzig. 



CLINICAL DIAGNOSIS. 



CHAPTER I. 
THE BLOOD. 

The whole quantity of blood in the body of an adult is 
equal to about -^ of the weight of the body — that is, on 
an average, 5 kilograms [10 lbs.]. 1 

The specific gravity varies in health between 1045 and 

i°75- 

The reaction of the blood is alkaline. 

The amount of hcemoglobin' 1 in the blood is about 14.57 
grams [4 drachms] in men, and 13.27 grams [31 
drachms] in women, in 100 ccm. [3 ounces] of blood. 
On heating, the haemoglobin is resolved into brown 
haematin and albumen. 

If some blood {e. g., that obtained from a blood stain on wood or 
linen), be heated to the boiling point with glacial acetic acid and a 
trace of common salt, and then slowly evaporated, there are formed 
brownish-yellow rhombic crystals of the muriate of hcematin, which 
is the same thing as hcemin or Teichmann's crystals. The prepara- 
tion should then be moistened with a little glycerine, and examined 
with a high power under the microscope. 

The red blood corpuscles measure in healthy individuals 

1 That part enclosed in [ ] is by the translator. 
a The amount of haemoglobin is determined by the quantitative 
spectral analysis or by means of a hsemochromometer. 



2 CLINICAL DIAGNOSIS. 

from 6.7 j.i to 9.3 /O The average size is 7.8 jn (Gram). 
Giant blood corpuscles (measuring from 10 to 15 yu) are 
found principally in the blood of the anaemic, and 
especially in those suffering from progressive pernicious 
anaemia. The dwarf Mood corpuscles measure from 2.2 to 
6 //, and are like the normal ones, only slightly more bi- 
concave. These are also found frequently in anaemia. 

By Poikilocytes are meant those red corpuscles of 
irregular form (pear-, club-, or biscuit-shaped) which 
are seen in all anaemic conditions. Microcytes are small 
spherical bodies, generally very rich in haemoglobin, and 

Fig. 1. 
Nucleated 
red blood corpuscles. Poikilocytes. 

Dwarf (W) 

Mood corpuscles. >-—«______ c 



A normal 
red blood 
corpuscle* 



<-> r^n J y^) ^ Giant 
f^ ^7 M"~^-^ - blood corpuscles. 



Microcytes. 

are found in many cases of burning and poisoning. Still 
we must very often consider them as artificial products. 
It is uncertain whether red corpuscles with crenated 
edges (thorn-apple-shaped corpuscles) appear in normal 
blood or not. When seen, they are generally considered 
artificial products caused by evaporation. Notwith- 
standing this, they are observed to form more quickly 
and abundantly in many cachectic conditions than in 
normal blood. 

1 /Li = the one-thousandth part of a millimetre, and is known as a 



THE BLOOD. 3 

Nucleated red blood corpuscles are seen in all severe 
cases of anaemia but they can only be recognized in 
stained preparations. 1 Very large nucleated blood 
corpuscles (megalocytes) are seen in progressive per- 
nicious anaemia. 

Blood-plaques (Bizzozero 2 ) = Hcematoblasts (Hayern 3 ) 
are colorless flat round discs about one half the diameter 
of a red blood corpuscle. They change their shapes 
very quickly when outside of the blood-vessel. The 
elementary granular masses are small, often angular, 
colorless granules with a diameter of 1-2/i. They consist 
in part of fat, and are probably for the most part disin- 
tegrated products of the blood-plaques. 

Fig. 2. Fig. 3. Fig. 4. Fig. 5. 

V 




Lymphocytes. Large mononuclear Polynuclear 

Small size. Large size. cell. cell. 

The white blood corpuscles (Leucocytes) are divided 
according to Ehrlich into : (i) Lymphocytes, which are 
about the size of a red blood corpuscle or somewhat 
larger, with a large round nucleus, and a very small, 
often scarcely visible, protoplasm. We distinguish two 
forms, a smaller and a larger, which latter is only the 
former in a more progressive stage of development. The 
lymphocytes have their origin in the lymphatic glands. 
(2) Large mononuclear forms, with large round or oval 
nucleus and broad protoplasmic body. These are the 
earlier stages of development of the third. (3) The 
large polynuclear form, containing a nucleus very much 
divided and lobulated, and which may be deeply stained 

1 Fortschritte der Medicin, 1884. 

3 Bizzozero : Vi re how's Archiv., Bd. xc. 

3 Hayem : Archive de Physiologie, iS 78-79. 



4 CLINICAL DIAGNOSIS. 

with aniline colors. They form by far the greatest 
number of the leucocytes, and are found almost exclu- 
sively in pus. Ehrlich designates as eosinophile cells those 
leucocytes in whose protoplasm a quantity of coarse, 
fatty, shining granules are seen, which are colored an 
intense red on staining a preparation of dried blood with 
a one-per-cent. watery solution of eosin. These cells 
have their origin in the marrow of bones, and are present 
in normal blood in small quantities only. In myeloge- 
netic leucaemia they are seen in large numbers. In 
lymphatic leucaemia it is principally the small lympho- 
cytes which are increased in number 

In order to examine the blood, it is generally sufficient to cleanse 
and dry the finger, and, with a needle or lancet, to make a quick and 
deep puncture in the tip. The drop of blood should then escape 
without squeezing the finger, and be dropped on a clean cover-glass, 
which is, in turn, dropped on the slide in such a way that the blood 
is spread out in a thin film. In order to see the blood-plaques, a 
drop of a one-per-cent. osmic-acid solution is applied to the finger, 
and the puncture is made through this drop. Instead of the osmic 
acid, which is simply a conservative fluid, a thin watery solution of 
methyl violet with 0.6 % of common salt may be used, which colors 
the blood-plaques and the nuclei of the nucleated red blood- 
corpuscles. In finer examinations of the blood, it is better to color 
a dried preparation {vid. Chap. xi. for preparation) with the follow- 
ing solution : 

IJ Hematoxylin, 2 grams [30 grains]. 
Alcohol, 
Glycerine, 

Distilled water, aa 100 grams [3 ounces]. 
Glacial acetic acid, 10 grams \2.\ drachms]. 
Alum in excess. 

This mixture should stand 3 weeks in the light, and a few granules 
of eosin should be added to it. The dry preparations remain from 
6-12 hours in the staining fluid, and then are to be washed off with 
water and examined. The nuclei of the nucleated red blood- 
corpuscles will be found to be stained intensely black. (Ehrlich.) 



THE BLOOD. 5 

The number of red blood corpuscles is, on an average, 
in men, in the normal condition, 5 million ; in women, 
4j- million, to a cubic millimetre [a millimetre equals ^ 
of an inch]. 

The number of white blood corpuscles varies between 
5,000-10,000, and is temporarily increased after a hearty 
meal. The number of blood-plaques is about 200,000 to 
the cubic millimetre. 

The proportion between white and red blood corpuscles 
is, in healthy individuals, 1-500 to 1-1,000. A proportion 
which is more than 1 to 400 must be considered as a 
pathological increase in the number of white corpuscles. 

Welker and Moleschott considered the proportion of white to red 
corpuscles to be 1:330 and 1.357. Dupe'rie found 5.500,000, red to 
5,000 white, or 1:1100 ; Malassez, 1:1200 ; Hayem, Bouchut, Du- 
brisay found, on an average, 1:500—1,000 ; Halla, 1:422-811. Laache 
and Otto found, on an average, for men 4.97 and 4.99 million, and 
for women 4.43 and 4.58 million red blood corpuscles. 

In order to count the corpuscles, a deep puncture is made into the 
finger-tip, and the escaping drop is sucked up into the me'langeur 
until it reaches the mark 1. The point of the instrument is then 
wiped off, and the diluting fluid 'is sucked up to the mark 101. This 
mixture of blood and diluting fluid 1 is well shaken and introduced 
into the counting chamber, and covered by the cover-glass, which 
should be lightly pressed on, and then the corpuscles are counted in 
each square, which is etched on the cover-glass. If a thousand cor- 
puscles have been counted in one square, the amount of corpuscles 
in a cubic millimetre can be calculated, since the dilution of the blood 
(1:100) and the depth of the chamber are known. By using the 
chamber of Thoma-Zeiss (depth ^ mm., 1 square = ^-J-^ cubic 
millimetre), the average number of corpuscles in a small square 

1 This fluid may be either a 3 % solution of common salt, or a 5 % 
solution of Glauber's salt, or Hayem's solution, which is corrosive 
sublimate, 0.5 grams [7 grains], Glauber's salt, 5.0 [1^ drachms], 
common salt, 2.0 [4 drachm], distilled water 200.0 grams [6 ounces]. 



6 CLINICAL DIAGNOSIS. 

is multiplied by 400,000 — that is, the whole number of corpuscles 
is to be divided by the number of squares which have been counted. 
It is more convenient to count the four small squares in one col- 
umn and calculate the average result of a large number of counts. 
This number, which is the number of blood corpuscles in any four 
squares, is then multiplied by 100,000. In using the chamber of 
Malassez or Hayem, which has a depth of \ mm., the average num- 
ber which is in a large rectangle (=20 small squares) is to be multi- 
plied by 10,000. If the blood dilution is 1:200 instead of 1:100, i. e. 
(up to mark 0.5 of the melangeur), the result should be multiplied 
by 2. 

Leucocytosis, that is, an increase of the leucocytes in proportion to 
the red corpuscle, is observed in numerous acute diseases (typhus 
abdominalis, erysipelas, etc.), also in cachectic conditions (cancer). 
This increase of leucocytes is often very great, and may even reach 
as high as 1 to 60 red corpuscles. 

In Leuccemia, the amount of red corpuscles as well as of haemoglobin 
is generally considerably decreased, so that the number of leucocytes 
is very considerably increased, and almost equals that of the red 
corpuscles ; indeed it may equal or exceed it. In the first stages of 
the disease, when the increase of the white corpuscles is often less 
than in severe leucocytosis, the diagnosis of leucaemia can be certain 
only when, in its further course, a rapid increase of leucocytes makes 
it very evident ; or when the proportion of white to red exceeds 
1:50. In myelogenetic leucaemia, there are numerous eosinophile 
leucocytes, and also nucleated red blood corpuscles to be seen. 
Ly?nphatic leucaemia is characterized by an increase of lymphocytes. 

In pseudoleuc&mia there is a slight decrease in the number of red 
corpuscles, and in the amount of haemoglobin, and no increase of 
the leucocytes. 

In the first few days after heavy loss of blood, the amount of red 
corpuscles as well as of the haemoglobin sinks markedly to over 50 % 
of the normal, whereas the number of leucocytes increases. In the 
period of convalescence, the amount of red corpuscles increases more 
quickly than that of the haemoglobin. In the secondary ancsmice, 
after typhus abdominalis, tuberculosis, malaria, lead poisoning, 
ankylostomiasis, nephritis, cancer, etc., the number of red cor- 
puscles as well as the amount of haemoglobin is diminished, and the 
amount of white blood corpuscles increased (leucocytosis). 



THE BLOOD. 7 

In chlorosis the amount of haemoglobin is very greatly decreased, 
whereas the number of red corpuscles is often very little or not at all 
increased. These are therefore very pale. The amount of white 
corpuscles is normal. 

In progressive pernicious anamia, the number of red corpuscles is 
enormously reduced, often to T V of the normal, whereas their size, 
and above all things, the amount of haemoglobin is increased. 

An increase in the number of red corpuscles is observed in thicken- 
ing of the blood in cholera, as well as in many heart affections. 

After long-existing malaria, pigment-containing leucocytes are at 
times seen in the blood. 

Micro-organisms are also observed in the blood— e. g., tubercle 
bacilli in miliary tuberculosis, bacilli lepra, bacilli anthracis, and the 
spirilla of relapsing fever. The latter can be seen with medium 
power, and are best recognized from the fact that when they come in 
contact with the red blood corpuscles, they impart to them a jerking 
motion ; or they can be recognized by coloring them as a dried prep- 
aration,' with a watery solution of gentian violet, as in the case of the 
bacilli anthracis. 1 

1 v. Appendix. 



CHAPTER II. 

TEMPERATURE. 

The temperature of the body is generally taken either 
in the axillary space or in the rectum [and under the 
tongue]. In the rectum it is about 0.5 — 1° higher than 
in the axilla. 

The temperature of the healthy individual measures 1 in 
the axilla between 3 6.2 C.[97.i°F.] and 37. 5 C.[99.5°F.]. 
The highest temperature is late in the afternoon, and the 
lowest, very early in the morning. An elevation of tem- 
perature can temporarily occur in consequence of bodily 
exertion, taking food, hot-baths, etc. A continuous ele- 
vation of temperature occurs in fever. According to 
Wunderlich we have : 

The temperature of collapse, 36 C. [96. 8° F.]. 

Sub-febrile temperature 37.5°-38° C. [99. 5 F.-100.4 
F.]. 

Slight fever 38°- 3 8.5° C. [ioo. 4 °-ioi.3° F.]. 

Moderate fever 39 C. [102.2 F.] morning ; 39. 5 
[103. i° F.] evening. 

Considerable fever 39.5 C. [103. i° F.] morning ; 40.5 
C. [io4.9°F.] evening. 

High fever over 39-5°C. [103. i° F.] morning; over 
40. 5 C. [104.9 F.] evening. 

1 In order to convert from one scale to the other, the following 
formula may be used : 

N° C = I n° R = f n° + 32 F. 



TEMPERA TURE. 9 

Hyperpyrexia, or fever over 41. 5 C. [106. 7 ]. 

Also in fever there is usually a morning remission and 
an evening exacerbation. Exceptionally, especially in 
phthisis, we have the reverse — typus inversus. The 
difference between the highest and lowest tempera- 
ture decides its type of the fever, thus : 

Febris continua = a daily difference of not more than 
i° C. [i.8° F.]. 

Febris remittals = a daily difference of not more than 
1.5° C. [2.7° F.]. 

Febris intermittens = in the course of the day the high 
temperature is varied by a period of no fever. 

In the course of a fever we distinguish : 

I. Stadium incrementi = a quick rise of temperature, 
generally accompanied by a chill or a slowly rising 
temperature. 

II. Fastigium = ora stage of highest temperature. Its 
transition to the next stage is known as the amphibolic 
stage. 

III. Stadium decrementi. The fever fall can follow 
either slowly, in course of several days, in which case we 
have lysis ; or quickly, the crisis. At the actual crisis 
the temperature falls rapidly (in one day) until it goes 
below normal. This fall is generally accompanied 
by a profuse perspiration. A high rise of temperature 
often precedes the crisis, which is called perturbatio 
critica. 

In acute infectious diseases we distinguish the stage of 
incubation — that is, the time between the moment of con- 
tagion and the outbreak of the disease. Also in acute 
exanthematous diseases there is the prodromal stage, or 
stage of the first morbid appearances, /. e., before the 
outbreak of the eruption. 



IO 



CLINICAL DIAGNOSIS. 



Morbilli— Measles. 

Incubation, ten days. Prodromal stage, three days, 
characterized by affections of the mucous membranes. 



Fig. 8. 
Temperature chart in Morbilli, 




It begins with chill and high 
fever ; and on the second 
or third day there is a slight 
fall of temperature. At the 
appearance of the eruption 
(on the face) the temperature 
rises again, and reaches its 
highest point when the erup- 
.6 tion is most widely dissemi- 
9 <5_ 8 nated. This is the stadium 

Prodromes. Eruption. Defervescence. floHtionis, and lasts three tO 

four days. The critical fall of temperature occurs on 
the sixth or seventh day of the disease, after which des- 
quamation begins. 

Scarlatina — Scarlet-Fever. 

Incubation, four to seven days. Prodromal stage, one 
to two days. It is characterized by angina. It begins 
with a chill and quick rise 
of temperature. At the end 
of the first or second day 
there is an outbreak of the c ° 
eruption (on the breast), and 41,* 
as it spreads the tempera- 40 
ture rises. Defervescence 
begins on fourth to seventh 
day of the disease, and comes 3 ' 
to an end slowly, with the 37 
paling of the eruption in 3 6, 
three to six days later. Desquamation then follows. 



Fig. 9. 

Temperature chart in 

Scarlatina. 



39 




TEMPERA TURE. 



II 



Variola— Small-pox. 

Incubation, nine days (nine to sixteen days), at the 
end of which time there is general disturbance of func- 
tions. The prodromal stage (two to five days) begins 
with a chill, 
with sudden 
rise of tern- c 
perature, and 41 
often on the 4<3 

second or 

39 
third day the 

. 38 

first signs of 

the eruption 37 
are observed. 3 6 
With the be- 
ginning of the pustulation there is a quick fall of tem- 
perature. Then comes a second and in the beginning 
a slight febrile movement, which reaches its climax on 
about the ninth day (fever of suppuration), preserves a 
remittent type for some time, and after a varying length 
ends in lysis (period of desquamation). About the six- 
teenth day the stadium decrustationis begins. 

Variolois — Varioloid. 





Fig:, to. Temperature chart in Variola. 


lllllllplllllll 

iiiiiiiiiiitll! 


I 


mmmmmmm 

Iliigglilliigl 



F° 
105.8 
104. 
102.2 
100.4 
98.6 



96.8 



Prodromes. Eruption. Fever of suppuration. Desquamation. 



Fig. tt. Temperature chart in Variolois. 



iiDHIIil 

HHHiiHH 




iiUmiHIIilllin 
JSMyiiHHiiliH 



The incubation 

et° and prodromal stag- 

8 es are the same as 

in variola vera, only 

much lighter. The 

second period of 

[ °°' 4 fever (fever of sup- 

98.6 puration) is want- 

968 ing. The period of 



12 



CLINICAL DIAGNOSIS. 



desquamation often begins as early as the ninth or tenth 
day, and is generally accompanied by slight rise of 
temperature. 

Varicella— Chicken-pox. 

The prodromes ase generally wanting. The eruption 
" j. S ? 5 " of the vesicles begins with 
slight fever. The vesicles dry 
up after three or four days. 

Typhus Abdominalis— 
Typhoid Fever. 

Incubation, seven to twenty- 
one days. The prodromal 
stage lasts several days to a 
week, and is accompanied by 
general disturbances. In the 
first week of the disease the 
temperature rises by degrees, 
accompanied by slight chills, 
and reaches, on the fourth or 
seventh day, its highest point. 
This continues as a febris con- 
tinua until the third week in 
the milder forms, and until 
the fifth week in the more 
severe forms. Then the morn- 
ing temperature begins gradu- 
ally to fall, while the evening 
temperature still remains high, 
until gradually lysis results, 
which in mild cases is in the 
fourth week. There is also 




TEMPERA TURE. 



13 



tumefaction of the spleen in the second half of the first 
week of the disease. Roseola occurs on the sixth to 
ninth day of the disease. 

Typhus Exanthematicus — Typhus Fever. 

Incubation varies from a few days to three weeks. 
The prodromal stage is not marked. The disease begins 
with a chill and rapid rise of temperature, and then it 
remains febris continua until the thirteenth to the seven- 



Fig. 13. Temperature chart in Typhus exanthematicus. 



j ^j^ ^i|r||M5 KinlJa &^fc^ 



41.0 
40.0 

39-° 
38.0 
37-o 
36.0 



jmmmmmmmmk 

■HBBBH 

iSilQHilliMiiesiii 



iiigiiiiliiliHiiiii 



Illll UJl J I fl 



F° 
105.8 
104. 
102.2 

100.4 
98.6 
96.8 



Eruption. 



teenth day. There are often remissions at the end of 
the first week. There is then a critical fall of tempera- 
ture, at times with transitory perturbatio critica. The 
eruption appears on the third to the sixth day after an 
inflammation of the mucous tracts. 

Febris Recurrens— Relapsing- Fever. 

Incubation five to seven days. The prodromal stage 
is not clearly marked. The fever begins with violent 
chill and a (high) sudden rise of temperature, which con- 
tinues as in febris continua until the fifth or seventh day, 
and then critically falls. After a period of apyrexia, last- 
ing about a week, there is again an attack of fever as at 



14 



CLINIC A L DIA GNO SIS. 



first, but not lasting so long. Often, after a period of 
seven days, there is a third attack, lasting one to two 
days. 

Fig. 14. Temperature chart in Febris recurrens. 




Malaria — Febris Intermittens. 

Incubation seven to twenty-one days. Prodromal 
stage is not marked. There is a chill, and the tempera- 
ture rises to very great height, and then sinks after a few 
hours to or below the normal. There is also strong per- 



Fig. 15- 

Temperature chart in Febris intermittens 



LIS 



According 
occurs every 



lllblllili 

"lUUHIIINHIJ 

fl&E&sasisBSSssas:: 

S!!SS!i3!5iiS5S5S:!SiiSg5£3S;3f 

HIIHIBIHr' 



spiration. 
the fever 

day, or every second and 
third day, it is called quo- 
tidian, tertian, and quar- 
tan intermittent fever. 
Febris intermittens dupli- 
cata is that type in which 
two attacks occur in quick 
succession in the course of 
the same day. Febris inter- 
mittens anteponens and post-ponens is that type in which 
the new attack of fever does not generally occur at the 
same hour of the day as the preceding attack, but sooner 
or later 



11IB1IHI11 




36 

Febris quotid ; tertiana ; quartana. 



100.4 
98.6 
96.8 



TEMPERA TURE, 



15 



Fig. 16. 

Temperature chart in 

Erysipelas. 



Erysipelas. 

Incubation one to eight days. It generally begins 
with a chill and high temper- 
ature. On the first or second 
day an inflammation of the c 
skin is observed. The tern- 

perature continues high as ilssani^BwiRsi 
long as the morbid process 4 °'° fillip j iliilfs!! 
spreads, and quickly falls as 39 '° |ig|[ isfill 
soon as the erysipelas ceases 38, ° f|g| 11110111 
spreading. With the spas- 37.0 §§§||||§|§ f||| 
modic spread of the erup- 36o 11511111 



105.8 

104. 

102.2 

100.4 

98.6 



96.8 
tion there is often found a remittent or intermittent fever. 

Pneumonia Crouposa. 

It begins with a chill and sudden rise of temperature. 
There is a continued fever during the spread of the 
peneumonic infiltration. On the fifth to the seventh 
day, and at times later, the crisis occurs, generally very 

Fig. 17. Fig. i3. 

Temperature charts in Pneumonia crouposa. 




suddenly, with strong perspiration, and, at the same time, 
a decrease in the frequency of the pulse and respiration. 
There is often a pseudo-crisis (v. Fig. 18) one or two 
days before the real crisis, but here the pulse and respira- 
tion remain high. 



CHAPTER III. 

ORGANS OF RESPIRATION. 

Topography of the Chest. 

The vertebral column has a normal curvature at the 
cervical, dorsal, lumbar, and sacral regions. A patho- 
logical curvature of the vertebral column convexly back- 
ward is called cyphosis. The same deformity, not curved 
but angular in character, is called gibbus. A curvature 
forward is called lordosis, and a lateral curvature scoliosis. 
A deforming curvature both laterally and backward is 
called cypho-scoliosis. 

The sternum in the adult is about 16-20 cm. [6-S 
inches] long. The angular prominence between the 
manubrium and body is called the angulus Ludovici. A 
bending inward of the xiphoid process, and of the lower 
part of the body, is called funnel breast. This latter 
shape of the thorax is acquired, and is seen in some 
occupations, e. g., in cobblers who press their instru- 
ments against the breast (cobbler's breast). When the 
costal cartilages in rachitis are pressed in by lateral com- 
pression, and the sternum has a keel shape, it is called 
pectus carinatum or chicken breast. 

The clavicle has a supra- and infra-clavicular groove 
in it. The external part of the latter is called Mohren- 
heim's groove. 

The scapula covers the second to seventh or third to 
eighth rib, and is provided with a fossa supraspinata and 

t5 



ORGANS OF RESPIRATION. 1 7 

a fossa infraspinata. Between the inner border of each 
scapula is the inter-scapular space. 

In order to determine the height of the thorax in front, 
we must follow the ribs by beginning to count at the 
second ; and behind the landmarks are the spinous pro- 
cesses, beginning with the seventh cervical, the vertebra 
prom in ens. 

The Harrison furrow has a horizontal direction at the 
level of the xiphoid process, and corresponding to the 
•normal attachment of the diaphragm. The region be- 
low this furrow to the angle of the ribs is called the 
hypochondrium. 

In order to determine the breadth of the thorax, we 
make use of the following perpendicular lines : 

(i) The median line. 

(2) The parasternal line, drawn half-way between the 
border of the sternum and the nipple. 

(3) The mammary line, drawn through the nipple, 
which, in healthy adults, lies between the fourth and 
fifth ribs, 10 cm [4 inches] distant from the border of the 
sternum. 

(4) The anterior, middle, and posterior axillary line ; 
the former drawn through the anterior, the latter through 
the posterior, boundary of the axilla. 

(5) The scapular line, drawn through the lower border 
of the scapula. 

The costo-articular line is a line drawn from the sterno- 
costal articulation to the tip of the eleventh rib. 

Size of the Thorax. The sterno-vertebral diameter of 
the thorax measures, in healthy men, 16.5 cm. [6J inches] 
above, and 19.2 cm. [7J inches] below, and in women it 
is somewhat smaller. The broad diameter of the chest is, 
in men, at the height of the nipple, 26 cm. [10 inches]. 



1 8 CLINICAL DIAGNOSLS. 

The circumference of the chest at the height of the 
nipple measures, in healthy men, 82.0 cm. [32J inches], 
after deep expiration, and 90 cm. [36 inches] after deep 
inspiration — that is to say, the maximum excursion of the 
thorax in respiration is 8.0 cm [3 inches]. In those who 
are right-handed, the circumference of the right half of 
the chest is 0.5 to 2.0 cm [J- to 1 inch] larger than the 
left. In left-handed persons the left side is slightly 
larger. 

Enlargement of one side of the chest is observed in pneumothorax, 
in effusions into the pleural sac (occasionally in pneumonia), often in 
mediastinal tumors, and in emphysema. In the latter disease there 
is, in severe cases, a barrel-shaped chest, while all the diameters, but 
especially the sterno-vertebral diameter, are enlarged, so that there 
results a permanent position of inspiration. Enlargements, especially 
of the lower opening of the thorax, occur with tumors and effusions 
in the peritoneal cavity. 

A narrow thorax may be congenital or acquired. A congenital 
narrowing of the thorax, in which it is long, small, shallow, while 
the intercostal spaces are broad and the sterno-vertebral diameter is 
especially smaller, is called a paralytic shape of the thorax, and is 
most frequent in phthisis pulmonum. 

An acquired narrowing of the thorax may be caused by an ab- 
sorption of a pleuritic exudation and shrinkage of the lungs, as in 
phthisis and cirrhosis pulmonum. 

The number of respirations in the healthy adult is from 
16 to 20, and in new-born children 44, a minute. 

The normal relation between the frequency of respiration 
and pulse is as 1:3 J to 4. 

The inspiratory enlargement of the thorax takes place 
in the male, principally by a deep descent of the abdo- 
men, and partly by the raising of the ribs by the scaleni 
and intercostal muscles — typus costo-abdominalis. In 
women, the inspiration is carried on more by raising 
the ribs — typus costalis. 



ORGANS OF RESPIRATION. 1 9 

The expiratory narrowing of the thorax is, under nor- 
mal conditions, caused only by the elasticity of the 
chest, without muscular assistance. 

Inspiration and expiration are generally of the same 
duration, and follow each other without the intervention 
of a pause. 

The lungs perform no active movement during respira- 
tion, but passively follow the movements of the chest wall 
and the diaphragm. In healthy individuals at rest, infre- 
quent and superficial respirations are sufficient to change 
the air in the lungs, but as soon as the amount of carbon- 
ic acid gas becomes too great in the lungs, the respira- 
tion becomes more frequent and deeper. This is seen in 
bodily exertion and fever, and also in disturbances of the 
circulation in consequence of heart troubles, and in all 
diseased conditions of the respiratory tract itself. If the 
blood is overloaded with carbonic acid gas to too great 
an extent, difficulty of breathing, i. e., dyspnoea, sets in. 

In inspiratory dyspncea, in which long-drawn inspirations are car- 
ried out with great muscular exertion, while the expirations follow 
more easily, the accessory muscles come into play. The sterno- 
mostoidei, scaleni, levatores costarum, serratus posticus superior, ser- 
ratus anticus major, pectoralis major and minor, levator scapulae, 
trapezius, rhomboidei major and minor, the extensors of the vertebral 
columns, the dilators of the nasal and oral cavities as well as of the 
larynx. This kind of dyspncea is observed in narrowing of the air 
passages — e. g., of the larynx, the trachea, and the bronchi, as well 
as in many diseased conditions of the lungs where there is a decrease 
of the respiratory surface. 

In severe inspiratory dyspncea, there is an inspiratory drawing in 
in the region of the xiphoid process and the lower border of the 
ribs. 

In expiratory dyspnoea, in which the narrowing of the chest is ren- 
dered difficult, and the length of the expiration is increased in pro- 
portion to that of the inspiration, the abdominal muscles and the 



20 CLINICAL DIAGNOSIS. 

serratus posticus inferior and the quadratus lumborum come into play 
as the accessory muscles of respiration. Expiratory dyspnoea is ob- 
served in cases of laryngeal polypus, more especially in emphysema 
and bronchial asthma. 

The mixed form of dyspnoea is made up of the inspiratory and 
expiratory dyspnoea. 

Changes in the Frequency of Breathing. 

Increase in respiratory frequency takes place : 

1. From nervous causes, in all affections of the mind, and in 
hysteria. 

2. From accumulation of carbonic acid gas in the blood, from 
bodily exertion, in fever, and in many forms of heart disease. 

3. In most diseases of the respiratory tract, such as pneumonia, 
phthisis, pleurisy, emphysema, accumulation of fluid and liquid in 
the pleural cavity, and finally, in all diseases of the abdomen — e. g., 
in peritonitis, tumors, ascites, which hinder the movements of the 
diaphragm. 

The relation between the frequency of the pulse and respiration 
may thus be changed from 1:4 to 1:1. 

Retarding of the respiration is observed in stenosis of the upper air- 
passages, and in cerebral diseases (as in hemorrhages, tumors, etc.). 

The Cheyne- Stokes respiration is a kind of breathing in which 
periods of complete cessation from breathing (apncea) are varied 
with periods of slowly rising respiratory movements, which become 
gradually deeper, and then, in turn, fall. This phenomenon is 
observed in many severe cerebral diseases, in heart disease, and 
uraemia. 

Spirometry. 

The total capacity of the lungs, i. <?., that quantity of air 
which, after forced inspiration, can be expelled by forced 
expiration, is about 3,000-4,000 ccm. [200-250 cubic 
inches] in a healthy man, or an average of 3,600 ccm. 
[230 cubic inches] ; in woman, 2,000-3,000 ccm. [125-200 
cubic inches], or an average of 2,500 ccm. [163 cubic 
inches]. This capacity increases with the growth of 
the body, so that about 22 ccm. \\\ cubic inches] of 



ORGANS OF RESPIRATION. 21 

expired air would be equivalent to about i cm. [i of an 
inch] in the adult. The capacity of the lungs is not so 
great in children, in old men, in all diseases of the 
stomach, and when the stomach is full. 

The complemental air is that amount of air which, after 
quiet inspiration, can be introduced by forced inspira- 
tion, and equals 1,500 ccm. [100 cubic inches]. 

The reserve air is that amount of air which, after quiet 
expiration, can be expelled by forced expiration, equal 
to about 1,500 ccm. [100 cubic inches]. 

The ordinary breathing air is that amount of air which 
is introduced and expelled in quiet respiration, and is 
equal to about 500 ccm. [33 cubic inches]. 

The residual air is that amount of air which remains 
in the lungs after the deepest exspiration, and equals 
about 1,600-2,000 ccm. [100-125 cubic inches]. 

Percussion of the Thorax. 

In percussion, the following qualities of sound are dis- 
tinguished : 

1. Clear and dull. 
(2. Full and empty.) 

3. Tympanitic and non-tympanitic. 

4. High and deep. 

Besides these, we have the metallic sound and cracked- 
pot sound (bruit de pot fele). 

In the normal thorax there is a clear sound over the 
lungs, and a dull sound over the organs not containing 
air. 

The Normal Boundaries of the Lung. 

The upper boundary of the lungs (apex) is, in front, 3-4 
cm. [1— i-| inch] above the upper border of the clavicle, 



22 CLINICAL DIAGNOSIS. 

and behind, it is on a level with the spinous process 
of the seventh cervical vertebra. 

The lower border of the lungs is, at the right border of 
the sternum, on a level with the sixth rib ; in the right 
mammary line it is at the upper border of the seventh 
rib ; in the anterior axillary line at the lower border of 
the seventh rib ; and in the scapular line at the ninth rib ; 
and at the vertebral column at the spinous process of the 
eleventh dorsal vertebra. On the left of, and near the 
sternum is the cardiac dulness. The boundary between 
the left lung and the tympanitic stomach is not easily 
defined. 

Topography of the Different Lobes of the Lung. 

The border between the upper and lower lobes begins behind, on 
both sides, at the level of the second and third dorsal vertebra, takes 
its course downwards and outwards, and reaches its limit on the left 
side in the mammary line at the sixth rib ; on the right side it divides 
about 6 cm. \o.\ inches] above the angle of the scapula into an upper 
and lower branch which embrace the middle lobe. The upper one 
takes a course slightly downwards, and reaches the anterior border 
of the lung at the height of the fourth or fifth costal cartilage ; the 
lower one separating the middle lobe from the lower lobe, goes 
straight down to reach the lower border of the lung at the mammary 
line. On percussion behind, therefore, we have, on both sides, the 
upper lobe only to the third rib, and from there on downwards the 
lower lobe ; in front, on the left side, only the upper lobe, and on 
the right side the upper and middle lobes. 

In quiet respiration the lung borders move but little ; 
in a supine position, the anterior lower border is about 
2 cm. [i inch] lower than in an upright position ; in lying 
on the side, the lower lung-border of the opposite side 
descends in the axillary line 3-4 cm. [i-i|- inches]. In 
extreme inspiration the respiratory movement can be very 



ORGANS OF RESPIRATION. 2$ 

considerable, and in forced inspiration, while lying on the 
side, the displacement may be as much as 9 cm. [3I 
inches]. The respiratory movement of the lungs (by 
filling the complemental space) is greatest in the axillary 
line. 

In emphysema the lower border of the lung is observed to be 
permanently lower, and in asthmatic attacks, temporarily lower than 
in the normal. 

The lower border of the lung is higher than normal in all contrac- 
tions of the lung and pleura, by pressure upward of the diaphragm, 
as well as by collections of air, and fluids, and of tumors in the ab- 
dominal cavity. The tipper border of the lung is lower than normal 
in shrinking of the apex in consequence of tuberculosis. 

The respiratory movements are less in emphysema and brown in- 
duration of the lungs, in beginning pleurisy, and in adhesion of both 
pleural surfaces. 

Dulness over the lung substance may be present : 

1. When that part of the lung next to the thoracic wall 
contains no air. Still, such a place must be at least as 
large as the pleximeter, and 2 cm. [1 inch] thick, in or- 
der to be recognized. 'The parenchyma of the lung may 
be without air in pneumonia and tuberculous infiltration, 
in haemorrhagic infarct, abscess, neoplasm of the lungs, 
and in atelectasis (by compression of the lung or by an 
obstruction in the bronchus leading to it). 

2. When a fluid or solid substance (tumor, pleuritic ef- 
fusion) is between the lung and the thoracic wall ; still, 
fluids in adults must amount at least to 400 ccm. [25 cu- 
bic inches] in order to be found. 

Pleuritic exudations collect in a non-adherent pleural cavity, first in 
the posterior inferior parts, and extend from there forward and up- 
ward. If the exudation has been formed while the patient was re- 
cumbent, the upper border of the dulness forms an inclined line from 
behind and above to in front and below. But if the exudation arise 



24 CLINICAL DIAGNOSIS. 

while the patient is walking about, then the line is almost horizontal. 
In exudations which are undergoing absorption, the upper border of- 
ten has a curved course, which is highest at the side of the thorax 
(curve of Damoiseau or Ellis). 

In inflammatory pleural exudation the borders of the dulness change 
little or not at all when the patient changes his position, since the 
exudation is generally encapsuled by the adhesions of the pleural sur- 
face. In hydrothorax, which is generally bilateral, although not at 
the same height on both sides, the level of the fluid changes only af- 
ter some time. In a collection of air and fluid at the same time in the 
pleural sac (pyo- and sero-pneumothorax) the border of the fluid be- 
comes horizontal at once, since in the upright position of the patient 
the fluid can be diagnosticated as a dulness in the anterior inferior 
half of the thorax, while in the supine position it sinks backward, and 
makes room in front for the tympanitic sound. 

The other organs are often displaced by the collection of large 
quantities of air or fluid in the pleural sac The displacement of the 
heart is not so great in left-sided pleural exudations as in right-sided 
ones. 

A tympcmitic sound in the thorax near a healthy lung is 
observed in the lowest part only of the left lung border- 
ing on the stomach. 

Pathologically, a tympanitic sound is observed : 

i. In condensation of the lung tissue, which permits of 
a percussion of the column of air in the bronchi and 
trachea, that is, of those air conductors which are nor- 
mally present in the lungs, e. g., in infiltration of the 
upper lobe. 

2. In the presence of pathological air-conducting cavi- 
ties. 

(a) In cavities which have firm walls, or in those 
which, with smooth walls, are separated from the thoracic 
cavity by infiltrated tissue, e. g., bronchiectatic or tuber- 
culous cavities, when these are at least as large as a 
walnut. 



ORGANS OF RESPIRATION. 25 

(b) In pneumothorax, so long as the air is not under too 
strong pressure ; for if the latter is the case, the sound, 
which was before tymrjanitic, will become dull and non- 
resonant. 

3. In relaxation of the lung tissue in the neighborhood 
of extended infiltrations and of pleuritic and pericarditic 
exudations ; thus, for example, there is often heard a 
tympanitic sound over the upper lobe of a lung, when 
there is a pneumonia of the lower lobe, or when the lung 
is compressed by a pleuritic exudation. 

4. In incomplete infiltrations of the lung tissue, when 
it contains air and fluid, as, for example, in the first and 
third stages of croupous pneumonia, in catarrhal pneu- 
monia, and oedema of the lungs. 

A metallic sound depends upon the prominence of the 
high upper tones together with the fundamental tone, 
and gradually decreasing reverberation. A metallic 
sound arises in the thorax from the presence of large 
smooth-walled cavities whose diameter is at least 6 cm. 
[2 1- inches]. 

The cracked-pot sound arises on strong percussion when 
the air is forced through a narrow opening out of a cav- 
ity (murmur of stenosis). It is also found in healthy 
persons, especially in children, if the chest is percussed 
during speaking or crying. Pathologically it is heard 
over all superficial cavities which are connected with the 
bronchi by a narrow opening, and at times also when the 
parenchyma of the lung is relaxed and infiltrated. This 
sound is clearer on strong short percussion when the pa- 
tient opens the mouth. If this sound is also tinkling, it 
is called metallic tinkling. 

The height and depth of the percussion note is distin- 
guished principally by tympanitic and metallic percus- 



26 CLINICAL DIAGNOSIS. 

sion note, and the note is deeper according as the cavity- 
is larger, and the opening is narrow. 

Wintrictis change of note is that in which the percus- 
sion note is higher when the mouth is open, and lower 
when it is closed. It is observed in cavities and pneu- 
mothorax, if they are in open communication with a 
bronchus, except, at times, in pneumonia and pleuritic 
exudation above. If this change of sound is observed 
on lying down, and is absent on sitting up, or vice versa, 
the bronchus leading to it is obstructed in certain posi- 
tions by the fluid contents (interrupted change of tone 
of Wintrich). 

Respiratory change of tone is at times observed ovei- 
cavities, by there being a higher tone in deep inspira- 
tion. 

The change of tone of Gerhardt, that is, different heights 
of the percussion note on sitting and lying, is observed 
over cavities which have unequal diameters and are 
partly filled with fluid. According as the patient sits up- 
right or lies horizontally, the fluid changes its position, 
and thus the longest diameter of the (oval) cavity, which 
diameter determines the height of the tone, is made 
longer or shorter. We may suppose that the longest di- 
ameter is horizontal when the percussion note is deepest. 
The most reliable sign of the formation of a cavity is to 
be regarded as the deeper tone on sitting up, by which 
the longest diameter is directed from before behind. 

The change of note of Bier mer is the percussion note in 
a pneumothorax (containing also fluid) which is deeper 
on sitting up than on lying down, since in the former 
position, the diaphragm is forced down by the pressure 
of the fluid, and thus the sounding cavity is made 
larger. 



ORGANS OF RESPIRATION. 2/ 

Auscultation. 

The Breathing Sound, 

We distinguish : 
i. Vesicular. 

2. Bronchial. 

3. Amphoric. 

4. Undetermined. 

5 . Metamorphosing . 

Vesicular breathing. Over the healthy lung is heard, 
during inspiration, a soft sucking murmur, and during 
expiration, a short uncertain or vesicular murmur, or none 
at all. In children we find an especially loud and sharp 
vesicular respiration : puerile respiration. Vesicular 
breathing represents a bronchial breathing which origi- 
nates in the trachea and the large bronchi, and is modi- 
fied by the overlying lungs. Vesicular breathing maybe 
imitated by saying/ or v softly. 

A diminution of vesicular breathing is heard in obstruction and 
narrowing of the bronchi, compression of the lungs, emphysema, and 
also when the lungs are pressed back from the thoracic wall by fluid 
(pleuritis), or solid substances (tumors). 

Increased vesicular breathing is observed in the swelling and nar- 
rowing of the bronchi, e. g., in bronchial catarrh. 

A lengthening and sharpening of the vesicular expiratory tone is 
heard when the exit of air from the bronchi is prevented by swelling 
of the mucous lining, or by an accumulation of the secretion in 
bronchitis and bronchial asthma. In the beginning of phthisis pul- 
monum, the same thing is frequently observed, but then it is confined 
to the apices of the lungs. 

When the inspiration is interrupted by two or more 
pauses, we call it jerking respiration. 

A systolic vesicular respiration is one in which the inspira- 
tory murmur is strengthened with each heart beat. 



28 CLINICAL DIAGNOSIS. 

Bronchial breathing, or sonorous breathing, which cor- 
responds to the tympanitic percussion note, is heard, in 
healthy individuals, over the larynx and trachea and inter- 
scapular space. We can imitate this sound by pronoun- 
cing k [the German^]. It is stronger and lasts longer in 
expiration than in inspiration. 

Under pathological conditions, we observe this kind of breathing 
when the respiratory murmur which arises in the larger bronchi, or 
in smooth-walled cavities, is transmitted unchanged through consoli- 
dated lung tissue to the chest wall, as, for example, in pneumonia or 
tuberculous infiltration, and in compression of the lung above a 
pleural exudation, except in phthisical or bronchiectatic cavities which 
lie near the thoracic wall, or which are surrounded by consolidated 
tissue. In this case, the bronchus which leads to it must be unob- 
structed. 

Amphoric breathing is a deep, hollow, buzzing sound, 
heard over cavities which give forth a metallic percussion 
note, e. g., in large, smooth-walled cavities at least as large 
as the closed hand, and in pneumothorax. This sound 
may be imitated by blowing over a jug or a bottle. 

An undetermined respiratory murmur is one which has 
neither the character of bronchial nor vesicular breath- 
ing. 

Metamorphosing respiration is characterized by an in- 
spiration which begins with vesicular breathing, and then 
passes over into bronchial breathing. It is heard princi- 
pally over cavities. 

Rales 

are respiratory murmurs caused by the collection of 
fluid or mucus in the air passages, or by the inspiratory 
current of air which forces apart the adhering bronchial 
walls. We distinguish rales according as they are : 
i. More or less plentiful. 



ORGANS OF RESPIRATION. 29 

2. Moist or dry. 

3. Mucous, crepitant, or sub-crepitant. 

4. Metallic or non-metallic. 

Dry rales may be purring or whistling (sibilant and 
sonorous). These are heard in accumulation of a thick 
secretion, and in oedema of the mucous membrane. 

Moist rales are divided into mucous, crepitant, and sub- 
crepitant, of which the former occur only over large cavi- 
ties, the latter over smaller ones. Crepitant rales are heard 
principally on inspiration, and occur in the first and third 
stages of pneumonia, in oedema of the lung, as well as in 
persons sick or convalescent, who have been for some 
time in a recumbent position, in whom the crepitant rale 
is heard in the posterior, inferior part of the lung, during 
the first deep inspiration. 

Metallic rales are heard under the same circumstances 
as bronchial breathing over consolidated lung tissue, 
cavities, etc. 

Metallic tinklitig rales of high musical pitch are heard 
over large cavities which give forth a metallic percussion 
note and amphoric breathing. To this class belongs the 
sound of drops of fluid falling into the cavity, as in 
pneumothorax. 

Auscultation of the Voice. 

On auscultating the chest of a healthy person while 
talking, the only thing heard is an indistinct murmur. 

This auscultatory sign is weakened by obstruction or compression 
of trie bronchi, or by a layer of air or fluid between the chest wall 
and the lung (pleurisy, pneumothorax, etc.). 

Bronchophony , or increased trans??iission of the voice, is 
heard where the sound waves of the broncho-tracheal 



30 CLINICAL DIAGNOSIS. 

column of air are conducted through the consolidated 
lung tissue to the chest wall, e.g., in pneumonia, cavities, 
above a pleuritic exudation, etc. Very strong bronchoph- 
ony is called pectoriloquy. 

A special kind of bronchophony is called cegophony, by 
which we understand a high trembling or bleating variety 
of voice. This is observed more frequently in incomplete 
compression of the bronchi at the upper border of a me- 
dium-sized pleuritic exudation, less frequently in hydro- 
thorax as well as over infiltrated lung tissue and cavities. 

A metallic sound of the voice is heard over large cavi- 
ties, and pneumothorax. 

Sucatssio Hippocratis, or a metallic splashing, is heard 
when air and fluid are present in the pleural cavity at the 
same time, if the patient be taken by the shoulders and 
shaken, as in sero- and pyopneumothorax. A dull or 
cooing sound is also occasionally heard over phthisical 
or bronchiectatic cavities. 

Pleuritic friction is heard when the pleural surfaces 
which, in a normal condition are smooth and shining, are 
roughened by fibrinous deposits, tubercular eruption, or 
abnormal dryness, and the pulmonary surface of the 
pleura rubs against the parietal surface during respira- 
tion. On adhesion of both pleural surfaces no friction 
sound is heard. The friction sound is generally of a 
jerking character, and is either soft or creaking. 

It is closely connected with respiration and ceases on 
holding the breath. It is distinguished from dry rales 
by being less regular, is not influenced by coughing, and 
is increased by pressure on the intercostal spaces. 
Further it appears to be more superficial and nearer the 
ear. It is strengthened by a strong inspiration. The 
pleuritic friction is often to be felt on palpation. 



ORGANS OF RESPIRATION. 3 I 

The vocal fi'e?7iitus, or pectoral fremitus, is the vibration 
of the voice transmitted through the bronchi and lung 
tissue to the chest wall. It is felt by laying both hands 
symmetrically on the chest wall while the patient speaks. 
The strength of the vocal fremitus is dependent upon the 
strength and depth of the voice, and upon the amount of 
resistance. 

Increase of vocal fremitus occurs in infiltration and compression 
of a circumscribed portion of the lung when the bronchus leading to 
this part is unobstructed. It is noticed in pneumonia, above pleural 
exudations, as well as over cavities with consolidated walls. 

Decrease and absence of the vocal fremitus occurs in very weak or 
absent voice, in obstruction or stenosis of the bronchus leading to 
that part where the chest wall is unusually thick, and where there is 
a layer of air or fluid between the lung and chest wall, principally 
over pleuritic exudations and pneumothorax. Still, in pleuritic 
adhesions between the lung and the chest wall, the vocal fremitus 
within the region of a pleuritic exudation or a pneumothorax may be 
partly present, or even increased. 1 

5 v. Appendix. 



CHAPTER IV. 
THE SPUTUM. 

The sputum consists not only of the secretion of the 
tracheal and bronchial mucous membrane, as well as of 
the pus from the cavernous portions of the respiratory 
tracts, but also it consists of the secretions of the pharynx 
and nasal cavity, as far as this is expectorated ; also it 
consists of the saliva and the secretion of the mucous 
membrane of the mouth. The remains of food are often 
mixed with the sputum. 

According to the principal constituents of the sputum, 
it is divided into — 

i. Mucous, 

2. Purulent, 

3. Serous, 

4. Bloody, 

and the combined kinds, or muco-purulent (principally 
mucous), purulo-mucous (principally pus), sanguineo- 
77iucous, sanguineo-serous, etc. 

We also distinguish according as the different con- 
stituents are intimately mixed with the mucus or not. 

Pure mucous sputa are found principally in incipient bronchitis. 
The sputa also of the vault of the pharynx are veiy thick and often 
consist of dried mucous masses. 

Pure purulent sputa are found in rupture of abscesses of the lung 
or neighboring organs, or from empyema of the bronchi. 

Serous foamy sputa are observed in oedema of the lungs. 

Sanguineo-mucous sputa, intimately mixed (brick-red to rust- 

32 



THE SPUTUM. 33 

colored), are found in pneumonia, hemorrhagic infarct, and car- 
cinoma of the lung (raspberry-jelly sputa) ; sangtdneo-serous sputa 
(prunc-juice sputa) are seen in oedema of the lung in the course of 
croupous pneumonia. This latter is not to be confounded with the 
blood-colored, sputa (brown-red, with a stale smell) which are often 
expectorated by malingerers and hysterical persons. 

Muco-purulent sputa, intimately mixed, are found in diffuse 
bronchitis and broncho-blennorrhoea, and in the latter disease the 
sputum divides in the spit-cup into three layers. In phthisis pul- 
monum the sputum is generally purulo-mucous and not mixed, while 
the pus is in streaks or balls, or nummular, and surrounded by 
mucus. In very large cavities the sputum may run together and be 
mixed. 

Pure bloody' sputa (haemoptysis) occur when a blood-vessel, or even 
a small aneurism in the neighborhood of the respiratory organs, is 
eaten through by ulcerations. The blood, in this case, differs from 
the blood in hemorrhage from the stomach principally by its being 
bright red and not mixed with food. 

The consistency of the sputum is dependent upon the 
amount of mucus in it, and not upon the solid sub- 
stances. 

Smell. A foul smell is caused by decomposition in the 
bronchi and the lungs (foetid bronchitis, gangrene of the 
lung) 

Color. Apart from the yellow-greenish color caused 
by the presence of pus, we may have red, brown, or yel- 
low-greenish color due to more or less changed condition 
of the blood-coloring substance, as in haemoptysis, infarct 
of the lungs, pneumonia, etc. 

A yellow-ochre color of the sputum is observed from the 
presence of hsematoidin, as in abscess of the lung. 

A green color may be caused by the coloring matter of 
the gall {e. g., pneumonia with icterus), by micro-organ- 
isms causing decomposition. 

Blue-colored sputa are seen in workmen in dyeworks ; 



36 CLINICAL DIAGNOSIS. 

The Char cot-Ley den crystals are pointed, colorless, shin- 
ing octahedra, and are especially found in bronchial 
asthma. They are seen most easily in the yellow fatty 
flakes and streaks in the sputa. 

Crystals of cholesterine, leucine, and tyrosiiie are seen 
occasionally in abscess of the lung and in putrid expec- 
toration. 

Of animal parasites are found in the sputum principally 
echinococcus hydatids and the ova of distomum. 

Micro-orga7iisms are present in all sputa, but are es- 
pecially abundant in putrid decomposition. Of especial 
importance are the bacilli of tuberculosis and of anthrax. 
In order to examine for the bacilli tuberculosis, parts are 
taken from the sputa, free from pus of such a kind as seems 
to come from a cavity. For directions how to prepare and 
color preparations, see Chapter XI. The examination for 
the coccus of pneumonia has, as yet, reached no diagnostic 
importance. Now and then threads of aspergillus (pneu- 
monomycosis aspergillina) are found in the sputum. 
These are best recognized in a preparation which has 
been treated with a 10 </ caustic potash solution. Also 
leptothrix threads, which are stained blue by a solution 
of iodine in iodide of potash, and sarcinse, as well as the 
rosettes of actinomycosis are all occasionally found in 
the sputum. 



CHAPTER V. 

LARYNGOSCOPY AND RHINOSCOPY. 

The larynx is situated between the upper border of the 
3d, and lower border of the 6th cervical vertebra during 
rest, and rises and falls during respiration, phonation, and 
deglutition. Very great respiratory excursions are made 
in stenosis of the larynx, when the head is inclined back- 
ward. Very few or no respirations are made in stenosis 
of the trachea, when the position of the head is inclined 
forward. 

The percussion of the larynx gives a tympanitic sound, 
a higher tone when the mouth is open, and a deeper one 
when the mouth is closed. The auscultation of the larynx 
and trachea gives loud tubal respiration which is called 
laryngo-tracheal respiration. 

Voice. 

We distinguish : (1) An open and a closed nasal voice, the 
former when (in paralysis or perforation of the soft pal- 
ate) the closing of the posterior nares is impossible, and 
the latter, when the nose is impermeable to air and is 
obstructed, (polypi, tumors, and stopping of the nose by 
coryza) ; (2) A hoarse voice or one accompanied by dis- 
turbing accessory sounds ; (3) A weak voice ; and (4) A 
want of voice (aphonia, the voice is without sound) ; (5) 
Falsetto voice j (6) Bass (an unnaturally deep voice in 
destruction of the vocal cords) ; (7) Diphthonia ; and 
(8) Tripartite voice in polypi of the vocal cords. 



38 CLINICAL DIAGNOSIS. 

The Muscles of the Larynx. 

The larynx is raised by the hyo-thyroid, and drawn down 
by the sternothyroid ; the epiglottis is raised 'by the thyro- 
epiglottic, and lowered by the ary-epiglottic muscles. 

The widening of the vocal chink (abduction of the vocal 
cords) is carried out by the posterior crico-arytenoid mus- 
cle. The same muscle turns the processus vocalis of the 
arytenoid cartilage outward. 

The closure of the vocal cords (adduction of the vocal 
cords) is carried out by the lateral crico-arytenoid mus- 
cle, which turns the processus vocalis inward, and by the 
inter-arytenoid muscle (transverse and oblique), which 
draws the base of the arytenoid cartilages to each other. 

The tension of the vocal cords is maintained by the 
crico-thyroid, which, by fixation of the cricoid cartilage, 
moves the thyroid cartilage forwards and upwards. 
Further, it is caused by the thyro-arytenoid muscles, the 
actual muscles of the vocal cords. 

Nerves of the Larynx. 

These spring from the vagus, and the motor branches 
are very likely originally from the accessorius. The 
superior laryngeal nerve supplies the crico-thyroid muscle 
with motor branches by its external branch ; by its inter- 
nal branch, the muscles of the epiglottis ; with sensory 
fibres the mucous membrane of the larynx. The inferior 
laryngeal nerve (recurrens nervi vagi) on the right side 
curves backward around the subclavian artery, on the left 
side around the arch of the aorta, goes upward between, 
the trachea and oesophagus, and supplies, all the remain- 
ing muscles not supplied by the superior laryngeal 



LARYNGOSCOPY 



39 



According to recent investigations of Exner l there exists, besides 
the superior and inferior laryngeal nerves, a median laryngeal nerve, 
which springs from the plexus pharyngeus. The motor and sensory 
division of the nerves is less simple than the above description. 

Paralysis of the Vocal Cords. 

In paralysis of the posterior crico-arytenoid muscle, the 
vocal cord cannot be moved outwards in respiration. 
The paralyzed vocal cord remains, during respiration, 
near the median line. 

In paralysis of both cords (Fig. 19, a) there is a small 
crack only between them, and there arises inspiratory 
dyspnoea. This same thing occurs in spasm and contrac- 

Fig. 19. 




Paralysis of them, crico- 
arytcenoideus posticus. 
Position of inspiration. 



Paralysis of the 
inter-arytrenoideus. 
Phonation. 



Paralysis of the 
thyro-arytsenoi- 
deus. Phonation. 



Paralysis of the recur- 
rent laryngeal on both 
sides. Respiration and 
phonation. 

Hon of the adductor muscles (lateral crico-arytenoid and 
inter-arytenoid). 

In paralysis of the hiter-arytenoid, the arytenoid carti- 
lages may approach each other with their processus 
vocales (lateral crico-arytenoid), but not with bases, and 
therefore in phonation there remains in the posterior 
third of the glottis (glottis respiratoria) an open triangle 
(Fig. 19, b.) 

In paralysis of the thyro-arytenoid, the tension of the 
vocal cord on phonation is incomplete, and the chord 



1 Sitzungsber. der Kaiserl. Akad. 

1884. 

8 v. Appendix. 



d. Wissensch. , 89, 1 u. 2. Wien, 




40 CLINICAL DIAGNOSIS. 

bowed outward with its free edge concave (Fig. 19, c). 
When, in addition to this, there is paralysis of the inter-ary- 
tenoid muscles, the chink remains open, 
and the processus vocales in front are 
bowed out. (Fig. 19, e.) 

In paralysis of the adductors (lateral 
crico-arytenoid and inter-arytenoid), the 
Faraiysis of the Mm. glottis remains open as a large triangle 

thyro-nrytsenoidei and in- ° ° 

ter-arytaenoidei. G n phonation (Fig. 1 9 d. ) In paralysis 

of the lateral crico-arytenoid alone, the glottis has a 
lozenge shape. 

In double-sided paralysis of the recurrent nerve, both 
vocal cords are immovable in the halfway position in 
phonation as well as in respiration (Fig. 19, d.), the posi- 
tion after death. In paralysis of this nerve on one side, 
the healthy vocal cord moves in respiration outward 
normally, and in phonation it approaches the paralyzed 
cord by crossing of the arytenoid cartilages. 

In paralysis of the crico-thyroid the vocal cord paralyzed 
is deeper than the healthy cord on phonation. Also in 
paralysis of the superior laryngeal nerve, there is immo- 
bility of the epiglottis on that side as well as anaesthesia 
of the mucous membrane of the epiglottis (absence of re- 
flex, swallowing the wrong way). 1 

1 v. Appendix. 



CHAPTER VI. 
CIRCULATORY SYSTEM. 
Inspection and Palpation. 

The apex beat of the heart. The 5th intercostal space 
on the left side between the parasternal and mammary 
line, is where the apex beat of the heart is to be found in 
healthy individuals. In children it often lies in the 4th 
intercostal space and more outward, and in old people it 
lies in the 6th intercostal space. The apex beat is lower 
during a deep inspiration, and lies more to the left, when 
the individual lies on the left side. 

The apex beat is lower down in hypertrophy of the left ventricle, 
aneurism of the aorta, and when the diaphragm is lower, as in em- 
physema and pneumothorax. 

The apex beat is high when the diaphragm is pressed upward by 
abdominal tumors, ascites, tympanites, and contraction of the left 
lung. 

Movement of the apex beat and of the cardiac dulness to the Tight is 
observed in pleural exudation of the left side, and in pneumothorax 
or in contraction of the right lung. The apex beat lies more to the 
left in hypertrophy and dilatation of the heart, in collections of fluid 
and air in the pericardium, and when the mediastinum is pressed to 
the left. 

The apex beat may be of normal strength, or weak- 
ened (or even absent), or increased, that is : 
(a) Simply strengthened. 
(£) Shaking. 
(c) Heaving. 

41 



42 CLINICAL DIAGNOSIS. 

A weakening of the apex beat is observed when the heart is unable 
to do its work (degeneration of the heart muscle, fatty heart) and 
when the heart is pressed backward from the chest wall by air or fluid 
in the pericardium or by an emphysematous lung. 

Increased strength of the apex beat is observed in increased activity 
of the heart (fever, mental excitement, exercise) and hypertrophy of 
the left ventricle. In the latter case, the apex beat is below and out- 
ward, whereas in hypertrophy of the right ventricle, the apex beat is 
extended toward the right side. 

Cardiac movement, visible to a greater extent, is seen in 
materially increased heart action, and when the heart is 
in contact with the chest-wall to a greater extent, as in 
contraction of the left lung. 

In advanced hypertrophy and dilatation of the heart, 
and in pericarditis, the cardiac region projects forward 
(voussure). 

A sinking in of the chest at the apex during the systole 
denotes adhesions of the heart with the pericardium. 

Pulsation in the epigastrium occurs in hypertrophy of 
the right ventricle, and when the diaphragm is low. 

Pulsation of the ascending aorta in the second right in- 
tercostal space, as well as of the pulmonary artery in the 
second left intercostal space, is observed in enlargement 
(aneurism) of these vessels, as well as in thickening of 
the borders of the lungs. When the closure of the valve 
of the pulmonalis may be felt on palpation, it is regarded 
as pathological, and is caused by stasis in the lesser cir- 
culation. 

Also in the heart region, pericardial friction and a sys- 
tolic or diastolic buzzing sound may be felt at all the 
valves, and the latter has the same importance as the 
murmur to which it corresponds. 

Pulsation in the bulb of the jugular vein is an important 
sign in insufficiency of the tricuspid. This pulsation is 



CIRCULATORY SYSTEM. 43 

synchronous with the systole, and shows that the bulbus 
valves are incapable of closing, on account of the exten- 
sion into the jugular vein of the pulsation. Venous pulse 
may be seen in the arm and in the liver, as in the case of 
a pulsation extending over the whole liver, and especially 
over the right lobe. A presystolic venous pulse is ob- 
served in overfilling of the right heart when the tricuspid 
valve is intact. An abnormal fulness of all the veins 
{cyanosis) is seen when the heart is barely able to work 
(valvular disease) or in obstruction in the lesser circula- 
tion. 

Diastolic collapse of the veins may occur in pericardial 
adhesion. 

A capillary pulse is seen in hypertrophy of the left ven- 
tricle (especially in insufficiency of the aorta) when the 
finger is drawn across the forehead. 

Percussion of the Heart. 

Cardiac dulness. In healthy individuals, the heart dul- 
ness begins above, at the lower border of the fourth rib ; 
the inner boundary is on the left border of the sternum, 
the outer boundary is formed by a line drawn from the 
fourth costal cartilage, curving convexly around, and end- 
ing at the apex beat. The inner and under side of the 
heart dulness measures 5-6 cm. [2-2-jL inches]. In chil- 
dren, the heart dulness is, relatively, somewhat greater, 
and in the aged, smaller. On deep respiration the heart 
dulness is decreased in size except in adhesions of the left 
lung. When the patient is on the left side, the heart dul- 
ness lies more outward. Increase of the heart dulness 
occurs in hypertrophy and dilatation of the heart. 

The dulness is increased from above, downwards and 
outwards in hypertophy and dilation of the left ventricle, 



44 CLINICAL DIAGNOSIS. 

while in hypertrophy and dilatation of the right ventricle 
the heart dulness is broader and lies over the right side 
of the heart. 

Hypertrophy of the left ventricle is observed in insufficiency of the 
aortic and mitral valve, in stenosis of the aortic valve (without dilata- 
tion), in aneurism of the aorta and atheroma of the arteries, in 
nephritis, and after long-continued and excessive bodily exertion, 

Hypertrophy of the right ventricle begins in an overloading or in 
obstruction in the pulmonary circulation (mitral insufficiency and 
stenosis, emphysema, contraction of the lung, defects in the pulmo- 
nary valves, and in insufficiency of the tricuspid). 

Increase of heart dulness in length and breadth occurs 
when the whole heart is hypertrophied, or when there is 
an effusion into the pericardium. In the latter case, 
the dulness is in the form of an equilateral triangle 
whose apex lies in the 3d-ist intercostal space, and, 
which lies on the right, beyond the right sternal border, 
and on the left, beyond the apex beat. 

There is also increase of the heart dulness in retraction 
of the left lung, chlorosis, and in fatty degeneration of 
the heart, and when the heart is pressed against the an- 
terior chest-wall by pressure upward of the diaphragm 
(by pregnancy, by tumors of the mediastinum, etc.). 

An apparent enlargement of the heart dulness occurs in 
infiltration of the left lung, and in a pleural exudation of 
the left side, 

A decrease in area of the heart dulness occurs in atrophy 
of the heart and in emphysema. On presence of air in the 
pericardium, there is observed, when the patient lies on 
the back, instead of heart dulness a tympanitic or metallic 
sound, which changes its seat as the patient moves. 

When the ductus arteriosus Botalli remains open, the heart dulness 
is in the shape of a small quadrilateral figure. 



CIRCULATORY SYSTEM. 45 

In case of situs viscerum transversus, the heart dulness and apex 
beat are found in the corresponding place on the opposite side. 

Aneurisms of the ascending aorta cause dulness and pulsation at 
the second and third sterno-costal articulation of the right side. 
Aneurisms of the arch and of the pulmonary artery cause the corre- 
sponding appearances on the left side. 

Auscultation of the Heart. 

Six sounds are heard over the heart. A systolic sound 
from each venous opening (mitral and tricuspid valves), 
a systolic and diastolic tone from the arterial openings 
(aorta and pulmonary). The systolic sound begins with 
the contraction of the ventricle, the diastolic with the 
beginning of the relaxation of the heart, and the closing 
of the aorta and pulmonary valves. 

The mitral is auscultated over the apex beat ; the tricus- 
pid, at the right sternal border at the fifth and sixth cos- 
tal cartilage ; the aortic, at the second intercostal space, 
on the right side near the sternum ; and the pulmonary 
valves in the second intercostal space on the left side, 
very near the sternum. 

Two sounds are heard at each opening. The second 
sound, at the mitral and tricuspid, is transmitted from 
the aorta and pulmonalis. Over the ventricles the accent 
is on the first sound (trochseus), over the great vessels it 
is on the second sound (iambus). The second aortic 
sound is normally as strong as or even stronger than the 
second pulmonary sound. 

A strengthened first sound is heard when the work of the heart 
»is increased, in hypertrophy of the ventricle in chlorosis, in mitral 
stenosis, also in fever. 

A weakened first sound occurs in weak conditions, in degeneration 
of the heart musculature, and in emphysema. 

Strengthening of the second aortic sound, occurs on increased arte- 
rial pressure (e. g., nephritis), and in atheroma of the aorta. 



46 CLINICAL DIAGNOSIS. 

A strengthened second pulmonary tone is heard in over-distension 
of the cavities, in obstruction in the lesser circulation (mitral insuffi- 
ciency, stenosis and emphysema, and cirrhosis of the lung). In mitral 
troubles, the strengthened second pulmonary sound is wanting as 
soon as the tricuspid insufficiency begins. 

Metallic-sounding heart tones are heard at times over 
lung cavities, in pneumopericardium, and dilatation of 
the stomach. 

Reduplication of the heart sounds is occasionally ob- 
served in health (depending upon respiration) in un- 
equal tension of the column of blood in both ventricles, 
which causes the valves on both sides to close at differ- 
ent times. 

A reduplication of the first sound is observed in hyper- 
trophy of the left ventricle, especially as a consequenc of 
granular atrophy of the kidneys. A reduplication of the 
second sound at the arterial openings is due, among other 
reasons, to mitral stenosis. 

The Heart Murmurs. 

Systolic murmurs are those heard from the beginning 
of the first heart sounds to the beginning of the second 
heart sounds, and all murmnrs from this point, to the 
first sound again, are called diastolic. A diastolic mur- 
mur which is heard immediately before the beginning 
of the next systolic, is called a presystolic murmur. The 
murmurs are heard after the sound or instead of the 
normal heart sound: These murmurs may be confined 
to one heart phase, or they may continue from the one 
to the next. The character of the murmur may be 
breathing, blowing, rasping, gushing (a diastolic murmur 
in aortic insufficiency), groaning, etc. 

The strength of a murmur is in proportion to the swift- 



CIRCULATORY SYSTEM. 47 

ness of the blood current, and to the amount of narrow* 
ing of the walls, and to their smoothness or roughness. 
The murmurs are transmitted most easily in the direction 
of the blood current which causes them ; therefore, in 
mitral insufficiency, a systolic murmur is heard most 
distinctly at the second costal cartilage of the left side, 
where the enlarged left auricular appendix lies near the 
pulmonary artery, close to the chest-wall. 

A systolic murmur of the mitral and tricuspid valves is 
indicative of an insufficiency of these valves, and a mur- 
mur at the aortic and pulmonary valves, indicates a 
stenosis of these valves. 

A diastolic murmur at the mitral and tricuspid valves 
is a sign of stenosis of these valves, and a diastolic mur- 
mur at the aortic and pulmonary means an insufficiency 
of these valves. Diastolic murmurs are generally of 
greater diagnostic importance than systolic murmurs, 
and we therefore lay more stress upon these, in the 
study of valvular affections. 

In heart murmurs, we make a distinction between 
pericardial and endocardial murmurs, and we divide the 
endocardial again into organic, and accidental or inor- 
ganic. The accidental murmurs are generally soft and 
blowing, and most frequently systolic, and very seldom 
diastolic. They are observed in faulty nutrition, and in 
contraction of the heart musculature in high fever and in 
changes in the blood (anaemia, chlorosis, hydremia). 
In progressive pernicious anaemia, and bad cases of 
chlorosis, accidental diastolic murmurs are also heard. 

Pericardial friction murmurs are caused by roughness 
of the pericardium, as in deposits of fibrin, tubercle, and 
carcinoma, pericarditis, and abnormal dryness of the 
pericardium. They are generally slight rubbing, jerk- 



48 CLINICAL DIAGNOSIS. 

ing sounds, and seem very near the ear. They are not 
always synchronous with the systole or diastole, but are 
often between both. They are influenced in their in- 
tensity by change of position, and by deep inspiration. 
The normal heart sounds, or endocardial murmurs, may 
occur with them. 

Extrapericar dial friction sounds, caused by friction be- 
tween the pericardium and the. pleura, are dependent 
upon the respiratory movements of the lungs as well as 
upon the heart's action. They generally cease on hold- 
ing the breath. 

Auscultation of the Blood Vessels. 

Over the carotid and subclavian two sounds are 
heard with each movement of the heart. The first, cor- 
responds to the systole of the heart and expansion (dia- 
stole) of the arteries ; the second, to the diastole of the 
heart (closure of the aortic valve) and to contraction 
(systole) of the arteries. The first tone arises from dis- 
tension of the arterial wall, the second is the sound, of 
the aortic valves transmitted along the vessels. The 
second sound is absent at the aorta and subclavian in in- 
sufficiency of the aortic valves. In stenosis of the aortic 
and sometimes in insufficiency of the aortic and mitral 
valves, in atheroma of the aorta, in fever, etc., there is 
heard over the carotid a murmur which is synchronous 
with the systole of the heart and is called an arterial dia- 
stolic murmur. 

In the more distant arteries (crural, brachial, radial) no 
sounds or murmurs are normally heard. On pressure, 
however, with the stethoscope upon the vessel, there is 
heard an arterial diastolic murmur, and by still harder 
pressure, there is a sound called pressure-tone heard. 



CIRCULATORY SYSTEM. 49 

Abnormal sounds in the small arteries (cubital, palmar, 
etc.), are heard in aortic insufficiency ; arterial murmurs 
are heard in insufficiency .of the aortic valve and in 
aneurisms. A double sound is heard over the crural artery 
in aortic insufficiency, in lead poisoning, and pregnancy. 

We auscultate the carotid at the point of insertion of the sterno- 
mastoid muscle into the clavicle and sternum, or at the inner border 
of this muscle, on a level with the thyroid cartilage. We auscultate 
the subclavian in the groove of Mohrenheim, or at the outer part of 
the supraclavicular fossa. 

The cubital and crural arteries are auscultated respectively in the 
bend of the arm and in the popliteal space. The stethoscope should 
not be pressed down at all. 

In small children from three months on, to the time 
when the greater fontanelle closes, a systolic blowing 
murmur may be heard at that point. 

A placental murmur is heard in the second half of 
pregnancy. 

When the jugular vein is partly distended (in all forms 
of anaemia, especially in chlorosis), a whistling, continu- 
ous murmur (bruit de diable) is heard over this vein, at 
the outer border of the sterno-mastoid muscle. This mur- 
mur is increased in intensity when the head is turned to 
the other side. In severe cases of anaemia, a murmur is 
also heard over the crural vein. 



CHAPTER VII. 
THE PULSE. 

The following varieties of pulse are distinguished. 

(i) The frequency of the pulse in healthy adults is on 
an average of 70 beats a minute (60-80), in children 
100-140, and in old men 70-90, sometimes more. 

The slower movement of the pulse (pulsus rarus) Is observed in 
icterus (from the effect of the gall acids on the heart ganglia), in irri- 
tation of the vagus, in paralysis of the heart ganglia and of the cer- 
vical sympathetic, in increased cranial pressure (first stage of basilar 
meningitis), in anaemia, in many diseased conditions of the heart 
musculature (fatty heart), and in stenosis of the aortic valves. 

Acceleration of the pulse (pulsus frequens) is observed normally on 
muscular exertion (to 140), at times in weakened individuals, and 
after taking food, and pathologically in fever, so that for every i° 
[i.8° F.] of increased temperature, there are about 8 pulse beats ; 
further, in paralysis of the vagus, and in excessively increased cere- 
bral pressure (in the last stage of basilar meningitis), in many neuroses 
of the heart (stenocardia, morbus Basedowii, etc.), in acute disease of 
the heart (endocarditis, pericarditis, and many cases of myocarditis), 
in almost all valvular troubles when there is disturbed compensation, 
and in collapse. 

(2) Rhythm (Pulsus regularis and irregularis). 

Irregular, arhythmic pulse is observed in extreme old age, and in 
many diseases of the heart and brain. An irregular pulse is of minor 
importance in advanced age, whereas in childhood it is observed in 
severe diseases only, as in basilar meningitis. By pulsus altemans is 
understood that kind of pulse in which a low pulse wave follows a 
high one. By pulsus bigeminus and trigeminus is understood a pulse 
in which there is a long pause after every two or three beats. Pulsus 

50 



THE PULSE. 51 

paradoxus occurs when the pulse is smaller with each inspiration or 
may even entirely disappear, as in inflammation of the mediastinum, 
pericardial adhesions, and stenosis of the air passages. Retardation or 
unegual size of the pulse, is where tfiere is a difference between the 
radial pulse of both sides, or between the upper and lower half of the 
body, and is observed principally in aneurism and narrowing of the 
arteries. 

(3) Quickness (pulsus celer or tardus, fast or slow 
pulse), /. <?., the quickness with which the arteries dis- 
tend and contract. The sphygmographic curve of the 
pulsus celer is steep and pointed, that of the pulsus 
tardus, long and shallow ; the tracing shows a rounded 
top to the pulse wave. 

Pulsus celer is observed in strengthened heart action, and in hyper- 
trophy of the left ventricle, as, for example, in Basedow's disease and 
in granular nephritis, and is most marked in insufficiency of the aortic 
valves (Fig. 21, No. VIII.). Pulsus tardus is observed in extreme 
old age {senile pulse, with rounded top, Fig. 20, No. II.), and in 
aortic stenosis. (Here the tracing shows a wave whose course is 
long drawn out.) 

(4) Size (pulsus magnus or parvus), that is, the height 
of the pulse wave. The pulse is larger in proportion to 
the impelling power of the heart, and to the amount of 
blood drawn into the arteries, and the less their tension 
is. A large pulse is observed in aortic insufficiency, in 
cardiac hypertrophy, in fever ; and a small pulse in 
stenosis of the cardiac openings, in cardiac weakness, 
and in chill. 

(5) Fulness (pulsus plenus or vacuus), i. e., when the 
arteries are partly filled only, and a pulsus plenus is ob- 
served in increased impelling power of the heart, and 
when the contractibility and elasticity of the arterial 
system remain the same, or in hypertrophy of the left 



52 



CLINICAL DIAGNOSIS. 



ventricle ; pulsus vacuus is observed when the arterial 
system is only partly rilled with blood. 

(6) Hardness (pulsus durus or mollis), i. <?., the de- 
gree of tension in the arterial system in proportion to the 
resistance felt to the finger. A hard pulse is difficult to 
suppress. A hard wiry pulse is observed in increased im- 
pelling power of the heart (hypertrophy of the left ven- 
tricle), as well as in a spasm of the arterial muscle (lead 
colic). A soft pulse is felt in mitral troubles, in fever, 
and anaemia. An apparently hard pulse is observed in 
atheroma of the arteries. 

When the pulse curve is traced with a sp/iygmograp/i, 
we notice an ascending and a descending line. Eleva- 




Normal pulse. 



Senile pulse. 
Pulsus tardus 



IV. 

Dicrotic. 



V. VI. 

Hyperdicrotic. Monocrotic. 



tions on the ascending part are called anacrotic, on the 
descending, catacrotic. According to the number of 

pulse is called catadicrotic, 
catatricrotic, etc. 
In the normalpnlse, 
the ascending arm 



catacrotic elevations 

Fig. 21. 




of the curve is 
straight, while the 
descending arm 
shows certain ele_ 

anecnons. vations due to the 

elasticity of the arterial wall (the elevation of recoil, Fig. 20, 
No. I., 0), and a greater elevation due to the recoil of the 
column of blood on the aortic valves, and one or more 



VII. 


VIII. IX. 


Pulse of tension. 
Lead colic. 


P. magnus etceler. P. parvus, irregu- 
Aortic insufficiency. laris. Mitral 



THE PULSE. 53 

smaller elevations due to the vibration in the tense elastic 
arterial wall. (Fig. 20, No. I., a and c). The greater 
the arterial tension, the more are these elevations of 
elasticity, and the more distinct is the elevation due 
to the recoil (lead colic, Fig. 21, No. VII., acute and 
chronic nephritis). If the arterial tension decreases, the 
elevation of elasticity disappears, and the elevation of 
recoil becomes greater and is nearer the beginning of the 
curve. It may be felt as a recoil wave, and in this case 
the pulse is said to be dicrotic. 

A dicrotic pulse is observed principally in fever, so that 
with increasing fever and decreasing arterial tension, the 
pulse becomes first subdicrotic (III.), then dicrotic (IV.), 
hyperdicrotic (V.), and finally, with extremely high tem- 
perature, it is monocrotic (VI.). With a subdicrotic pulse, 
the elevation of recoil appears before the descending line 
has reached the base of the curve ; in complete dicrotic 
pulse, after it has reached the base of the curve ; in 
hyperdicrotic pulse, the elevation of recoil belongs to 
the ascending part of the next wave ; and in monocrotic 
pulse, no elevation of recoil can be recognized. 

A slow ascending line, round and broad top, no eleva- 
tion of elasticity, and a slight recoil, are observed in 
atheroma of the aorta (pulsus tardus, senile pulse). A 
slight elevation and long line of descent is observed in 
stenosis of the aortic valves. Anacrotic elevations in the 
ascending branch of the curve (Fig. 20, II.) occur in dis- 
eases of the arterial wall or aortic valves, by the disten- 
sion of the arteries being slow and jerky. 

The pulse curve in the veins is the reverse of that in the 
arteries. This ascends slowly and falls quickly. The 
ascending branch of the curve is anadicrotic, the second 
elevation coming from the contraction of the right auricle. 



54 CLINICAL DIAGNOSIS. 

The venous pulse observed in insufficiency of the tricus- 
pid, is characterized by its beginning in the diastole, 
reaching its maximum in the systole, and continuing through 
the same. The venous pulse, however, occurring with a 
normal tricuspid valve, falls immediately before the 
beginning of the systole, i. <?., before the ascent of the 
arterial blood wave. To be convinced of this it is only 
necessary to put the finger on the carotid and follow the 
venous pulse with the eye. The wave appearing in tri- 
cuspid insufficiency, and outlasting the arterial pulse, 
comes from the blood wave, which is thrown back during 
the systole through its insufficient valve into the auricle 
and upon the venous system. 1 

1 v. Appendix. 



CHAPTER VIII. 
DIGESTIVE AND ABDOMINAL ORGANS. 

The Teeth. 

The milk teeth are twenty in number, namely, 2 inci- 
sors, 1 canine, and 2 bicuspids on each side of each jaw. 
The milk teeth come through between the 7th month and 
the end of the 2d year. The first to appear is the middle 
inferior incisor in the 6th-8th month. Then follow 
the remaining six in the 7th~9th month. Then come 
the upper and lower anterior bicuspids in the I2th-i5th 
month, and at the end of the second year appear the 
posterior molars. In the 7th year the 2d dentition be- 
gins, and the milk teeth fall out in about the same order 
in which they came. 

The permanent teeth are 32 in number, namely, 2 inci- 
sors, 1 canine, 2 bicuspids, 3 molar on each side of each 
jaw. First appears the anterior molar, which comes 
through behind the temporary bicuspid in the 4th~5th 
year. In the 7th year, the central incisors follow ; in the 
8th year, the external incisors, /. e., first the lower and 
then the upper. In 9th-ioth year, the anterior bicuspid 
appears ; in the ioth-nth year, the canine ; in the nth- 
12th year, the posterior bicuspid. The second (middle) 
tricuspid appears between the I2th-i3th year; the pos- 
terior tricuspids, or wisdom teeth, between the 16th and 
30th year. 

55 



56 CLINICAL DIAGNOSIS. 

The Saliva. 

The normal saliva has a specific gravity of 1002 to 
1006 ; the normal reaction is alkaline, but it is often 
made acid by decomposition in the mouth, as, for exam- 
ple, in diabetes mellitus. The saliva contains only traces 
of albumen, and sometimes, but not always, sulphocyan- 
ide of potassium (SCNK). This may be recognized by 
adding a few drops of hydrochloric acid, and a diluted 
solution of chloride of iron, when a blood-red color is 
formed, which is taken up on shaking with ether. In 
the saliva there is also a diastatic ferment, which may be 
shown by adding to a test-tube of saliva a diluted starch 
paste, and letting it stand at the temperature of the body. 
In a few minutes sugar is formed which may be shown 
by Trommer's test. 

CEsophagus. 

The length of the oesophagus is, in adults, on an aver- 
age 25 cm. [8|- inches] ; 8 cm. [3J inches] below its be- 
ginning, it is crossed by the bronchus. The distance 
from the upper incisors to the beginning of the oesopha- 
gus is about 15 cm. [6 inches]. Accordingly, when the 
oesophageal sound passes the distance of 40 cm. [15I 
inches], counting from the upper incisor, we know it is 
in the stomach, and if after 23 cm. [9 inches] it comes 
upon an obstruction, we may infer that there is a steno- 
sis or diverticulum at the point where the bronchus 
crosses the oesophagus. If the sound penetrate 60-70 
cm. [25.J— 27J inches] and its point can be felt through 
the abdominal walls below a line drawn through the an- 
terior superior spine of the ilium, then there is disten- 
sion of the stomach. 

On auscultating the oesophagus just to the left of the 



DIGESTIVE AND ABDOMINAL ORGANS. 57 

vertebral column, there is heard a short murmur just af- 
ter swallowing, and this murmur in stenosis may be de- 
layed, weakened, or may even disappear. On ausculta- 
tion in the epigastric fossa (or still better, at the angle 
behind the left costal curvature and the ensiform carti- 
lage) there is heard, generally immediately after swallow- 
ing, a short murmur, or a few seconds later, a longer 
murmur (the murmur of Kronecker and Meltzer and the 
primary and secondary murmur of Ewald). 

Stomach. 

Five sixths of the stomach are to the left and one sixth 
to the right of the median line. The fundus lies under the 
left leaflet of the diaphragm. The lesser curvature of 
the stomach and the pylorus are covered by the left lobe 
of the liver. The pylorus lies in the right sternal line 
about at the height of the tip of the ensiform cartilage. 
The greater curvature takes a course about 2-4 cm. [1 
inch] above the umbilicus. 

In order to mark out the stomach by percussion, we 
must first determine the position of the diaphragm, and 
the borders of the liver and spleen dulness. Between 
these organs we come upon the deep tympanitic sound 
of the stomach, which may be more or less easily distin- 
guished from the high tympanitic percussion note of 
the intestines. The half -moon shaped space of Traube is 
the upper part of this tympanitic space, which lies be- 
tween the lungs on one side, and liver and spleen on the 
other. Fuller particulars as to the size of the stomach, 
are obtained by artificially distending the same with 
carbonic acid gas. This is done by administering a 
teaspoonful of bicarbonate of soda and tartaric acid, as 
separate doses, in water. When the stomach is partly 



58 CLINICAL DIAGNOSIS. 

filled with food, there is found, on percussion in the 
lower part, a dulness, which changes its position with 
the movements of the patient. The stomach is consid- 
ered dilated, when the greater curvature reaches below 
the umbilical line. There is also a splashing noise heard 
on shaking the patient. 

In palpation, attention should be directed to circum- 
scribed parts which are painful on pressure. They may 
point to an ulcer or tumor (carcinoma). Tumors of the 
stomach, in distinction from those of the liver, do not 
move vertically during respiration. 

Examination of the Stomach's Contents. 

Under normal conditions, the stomach digestion of a 
moderately hearty meal is over in 6-7 hours and the 
stomach is again empty. If, after this time, lavage of 
the stomach shows large quantities of food debris, it 
must be considered as a sign of disturbed digestion. 

To accurately define the digesting strength of the 
stomach, and the amount of acid the gastric juice con- 
tains, a sample of the digestive mixture 1 is drawn off 
with a stomach sound two hours after eating. 

Test of the Amount of Acid Contained. — The reaction is first 
tested with litmus paper. An acid reaction may be caused by hy- 
drochloric acid, or by the organic acids (lactic, butyric, acetic). To 
test for hydrochloric acid, a few drops of a diluted watery solution of 
methylviolet or tropseoline are added to a few drops of filtered gastric 
juice. Even 0.1-0.2 % of hydrochloric acid causes a distinct colored 
precipitate of blue or reddish brown, while a much greater concentra- 
tion is required to produce the same precipitate in the case of the 



1 According to Leube, the gastric-juice secretion is excited by 
pouring 100 ccm. [6 ounces] of ice-water into the stomach after it 
has been washed out with tepid water, and ten minutes later syphon- 
ing off a sample. 



DIGESTIVE AND ABDOMINAL ORGANS. 59 

other acids. To test for lactic acid, a few drops of the filtered gastric 
juice are added drop by drop to 1-2 drops of a reagent consisting of 
3 drops of the solution of the sesquichloride of iron, 10 cm. \z\ 
drachms] of a 4 # carbolic-acid solution, and 20 cm. [5 drachms] of 
water. The original amethyst blue is turned yellow by lactic acid, 
and pale gray by hydrochloric acid and butyric acid (Uffelmann). 
When lactic and hydrochloric acids are both present, the former is 
removed with ether, and the residue is tested for the latter. All 
these tests are not very reliable, and are influenced by the degree of 
the acidity and the presence of such bodies as the peptones, neutral 
salts, etc., preventing the reaction. Still, it can generally be pre- 
sumed that when the reaction shows a large amount of hydrochloric 
acid present, a carcinoma of the stomach is probably to be excluded. 
In order to test the digesting strength of the gastric juice, to two 
test-tubes containing gastric juice a bit of washed fibrin, and to one 
of these test-tubes a few drops of I % hydrochloric acid, are added, 
and both tubes are put into the incubator at body temperature. If 
after 6-12 hours the fibrin in neither tube is dissolved, there is evi- 
dently want of pepsin in the sample, and if the fibrin in the gastric 
juice containing the 1 % hydrochloric acid is alone digested, then we 
surmise that this gastric juice contains pepsin, but no hydrochloric 
acid. When the gastric juice is normal, the fibrin in both tubes 
should disappear in 1-2 hours. 

Vomited matter may contain : 

Mucus (in gastric catarrh), 

Swallowed saliva (in the morning sickness of drunk- 
ards). This may be recognized by its containing ferro- 
cyanide of potash (showing a blood-red color on addition 
of a solution of chloride of iron). 

Blood (ulcer and carcinoma of the stomach, cirrhosis 
of the liver). This may be either unchanged, or is di- 
gested to a brown, coffee-ground mass, due to its long 
stay in the stomach. In this latter case, the red blood- 
corpuscles are dissolved, and the haemoglobin changed 
to hsematin, which may be shown with the haemin test 
(via 7 , page 1). 



6o CLINICAL DIAGNOSIS. 

Gall is also found when the vomiting is frequent and 
of long duration. In uraemia, urea and carbonate of am- 
monia are found in the vomitus. 

Remains of food, which may be more or less altered, 
either by the process of digestion or by micro-organisms. 
The effects of the latter causing fermentation and de- 
composition, form lactic, butyric, and acetic acids out 
of the carbohydrates (starch and sugar) ; free fatty acids 
out of the neutral fats ; peptones, leucin, tyrosin, phenol- 
indol, skatol, sulphuretted hydrogen, and ammonia out 
of the albuminous substances. These latter are products 
of advanced decomposition, and are found principally 
when the contents of the small intestines regurgitate into 
the stomach and are vomited (vomiting of faeces). 

On microscopical examination of the vomitus, there are 
found apart from the remains of food (cross-striped 
muscular fibres, fat, starch, vegetable substances, etc.) 
pavement epithelium of the mouth and oesophagus, and 
more seldom cylindrical epithelium of the stomach, as con- 
stant leucocytes, schizomycites of the most varied kind ; 
sometimes yeast-cells, sarcinse, and oidium albicans. 

Liver. 

The upper border of the liver dulness begins at the 
lower border of the right lung and of the heart. The 
lower border is, in healthy individuals, in the axillary 
line between the tenth and eleventh ribs, at the curvature 
of the ribs in the mammary line ; and at the median line 
it lies between the xiphoid process and the umbilicus ; it 
then takes a curved direction upwards and reaches the 
diaphragm and generally the heart apex between the 
parasternal and mammary line. In deep inspiration, 
when the patient lies on the left side, the liver dulness 



DIGESTIVE AND ABDOMINAL ORGANS. 6 1 

is smaller, because the lung border comes down further. 
The lower border of the liver moves up and down slightly 
during respiration. 

The liver is forced down in emphysema, pneumothorax, pleurisy, 
and pericardial exudations. 

It is pushed upwards in contraction of the right lung and in 
increased pressure from below in the abdominal cavity, as in peri- 
tonitis, ascites, tumors, and pregnancy. From this cause the anterior 
edge of the liver may be turned up,. causing a material decrease in the 
size of the liver-dulness. 

Hypertrophy of the liver occurs in the first stage of cirrhosis, 
in congestion, in fatty and waxy liver. Decrease in the size of 
the liver-dulness occurs in atrophic nutmeg liver, acute yellow atro- 
phy, in the second stage of cirrhosis, and when the transverse colon 
lies between the abdominal wall and the liver. When air enters the 
peritoneal cavity, there is complete absence of liver-dulness in the 
median line. 

In healthy adults the surface and edge of the liver cannot be felt. 
It is, however, resistent and to be felt in congestion, cirrhosis, amy- 
loid degeneration, multilocular echinococcus, and not so easy to be 
felt in fatty liver. Inequalities of the liver-surface and tumors may 
be easily felt in cirrhosis, syphilis of the liver, abscess, carcinoma, 
and echinococcus. When the echinococcus cysts are present there is 
a slight fluctuation to be felt over the liver (hydatid purring). 

In the liver of tight lacing that part of the right lobe is felt as 
a round tumor below the ribs and separated from the rest of the liver 
by a horizontal furrow. In wandering liver, the organ is dislocated 
downwards (also in the upright position) and abnormally movable. 

The enlarged gall bladder can sometimes be percussed about 5 cm. 
[2 inches] to the right of the median line at the lower border of the 
liver and can be felt as a round tumor. 

The Spleen. 

The normal splenic dulness is in the left hypochon- 
drium, between the ninth and eleventh ribs and reaches 
forward to the costo-articular line (drawn from the left 
sterno-clavicular articulation to the tip of the eleventh 



62 CLINICAL DIAGNOSIS. 

rib) and backward to the spinal column. The height 
(breadth) of the spleen-dulness is, in the middle axillary 
line, 5-6 cm. (2-2 1 inches). On inspiration and when ly- 
ing on the right side, the splenic dulness is made smaller 
by the lower border of the left lung moving down. 

The spleen is lower down in a pleural exudation of the left side, 
in pneumothorax, and emphysema. In ascites, tympanites, tumors 
of the abdomen, the spleen is pressed upward against the diaphragm 
and the dulness is made smaller. 

Hypertrophy of the spleen is observed in almost all infectious 
diseases (typhoid fever, typhus, pyaemia, the acute exanthematous 
diseases, beginning secondary syphilis, in many forms of pneu- 
monia, etc.) ; further in leucaemia, amyloid degeneration, cirrhosis 
of the liver, heemorrhagic infarct of the spleen, echinococcus, and in 
the severer forms of intermittent fever. When the spleen is greatly 
hypertrophied the end may be felt under the left border of the ribs. 

An apparent hypertrophy is observed in pleural exudations of the 
left side and in infiltration of the left lung. 

The splenic dulness is absent in wandering spleen and on the pres- 
ence of air in the peritoneum when the patient lies on the right 
side. 

In situs viscerum transversus the splenic dulness is on the right 
side and the hepatic dulness on the left side. 

Abdomen. 

The abdomen emits under normal circumstances a 
tympanitic sound of varying height in all parts. 

A sinking in of the abdomen is observed when the intes- 
tines are empty and contracted (in inanition, meningitis, 
lead colic). 

Distention of the abdominal walls occurs in overloading 
of the stomach and intestines with air (tympanites) or 
fluid, in collections of air or fluid in the peritoneum and 
intestines. 

In collection of free fluid in the peritoneum, ascites 



DIGESTIVE AND ABDOMINAL ORGANS. 63 

(in heart disease and congestion of the portal system, 
especially cirrhosis of the liver) the abdomen is laterally 
distended, and in the middle, flat when the patient is 
recumbent. The fluid, which may be found by dulness 
and fluctuation, shows a horizontal boundary line above 
when the patient stands, and changes its position quickly 
when the patient moves about. 

In inflammatory exudations of the peritoneum, the abdomen is 
generally equally distended, and the fluid is often encysted and im- 
movable. If the fluid is very great in amount the intestines do not 
reach the abdominal wall (also when the mesentery is shorter) and 
there is everywhere dulness on percussion. 

When air enters the peritoneum, it always seeks the highest level 
and causes the liver-dulness, i. e., its central part, or the splenic dul- 
ness, to disappear, according to the position of the patient. In 
tumors there is, according to the position, an unequal distention of 
the abdomen, e. g. , in tumors of the liver and spleen there is a dis- 
tention in the upper part of the abdomen, and in uterine and ovarian 
tumors in the middle and lower parts. 

In peritonitis there is occasionally a friction sound to be felt and 
heard. 

Addendum. 



The Faeces. 

The faeces consist of 

(1) The remains of the food altered by the processes 
of digestion and decomposition. 

(2) The digestive juices in the intestines, and 

(3) Certain products of excretion which come from 
the body through the glands opening into the intestines, 
e. g., the salts of the heavy metals, iron, lead, mer- 
cury, etc. 

As to the consistence we distinguish^;;/, thick fluid, thin 
fluid, and watery. The two last kinds are not considered 



64 CLINICAL DIAGNOSIS. 

normal unless they are caused by the diet or by purga- 
tives. Watery passages (diarrhoea) appear when the food 
passes through the intestines so quickly that the absorp- 
tion is incomplete, or, more rarely, when there is an exu- 
dation into the intestines, as in dysentery. 

Mucus may form a glassy covering to the faeces, or be 
mixed in large coarse lumps with it (in affections of the 
large intestine, even in its lower parts), or it is intimate- 
ly mixed in small particles with the faeces (in disease of 
the upper part of the large or small intestine). If the 
mucus is colored with gall, or if it reacts with the test of 
Gmelin, we may consider that the small intestine is af- 
fected. Purulent mucus is observed in ulceration of the 
intestines. Large cylindrical masses of mucus are passed 
in the so-called mucous colic (Nothnagel). 

The color of the faeces is caused principally by the 
coloring substance of the gall. Generally the coloring 
substance is altered by bacteria and reduced to hy- 
drobilirubin, but sometimes the coloring substance of 
the gall appears unchanged, as in the yellow and green 
passages of infants, and when the peristalsis is especially 
rapid. 

If the gall be absent in the intestine (as in icterus) the 
passage contains abundant fat, and appears therefore 
gray, greasy, and clayey, and on shaking with water 
there is a peculiar play of colors noticed. The passages 
show an abundant amount of fat and a similar appearance 
when the absorption of fat does not take place on ac- 
count of various diseases of the intestinal mucous mem- 
brane or of the chylopoetic system. 

The color, as well as the consistence and amount, of the 
faeces is also dependent upon the food taken. In an 
almost exclusively meat diet, firm, brownish-black fseces 



DIGESTIVE AND ABDOMINAL ORGANS. 65 

in small amount are passed. In a diet of starchy foods 
(bread, potatoes) the passage is yellow-brown, soft, 
foamy, and in large quantity ; in an exclusively milk 
diet, yellow- white and firm ; in an egg diet, soft and white, 
etc. Further, the color is changed by drugs, e. g., iron 
and bismuth make it black, forming sulphate of iron 
and sulphate of bismuth ; mercurial preparations, and 
especially calomel, greenish brown, making a combina- 
tion of the coloring matter of the gall with mercury ; 
rhubarb, yellow-brown, and logwood preparations, red- 
dish brown. Blood from the upper intestinal tracts 
mixed with the faeces makes a tarry, blackish-red color ; 
but if the blood comes from the lower parts (in dysentery 
and haemorrhoidal bleeding), it is generally red and un- 
altered. 

In typhoid fever the stools generally have- the appear- 
ance of a badly cooked pea-soup ; in cholera they re- 
semble rice water ; and in dysentery they contain bloody 
mucus. 

In the microscopical examination of the faeces there are 
found shreds of cross-striped muscle fibres and of the 
animal tissues ; further, vegetable substances, such as 
spiral threads, but rarely starch kernels. Fat appears in 
the form of drops and of glassy clumps, as well as 
needle-shaped crystals. The latter point to a disturbed 
fat absorption, and occur most abundantly when the gall 
does not flow into the intestine. Also the coffin-top- 
shaped crystals of the ammonia-phosphate of magnesia, 
and clumpy crystals of other lime salts, as well as the 
needle-shaped crystals of Charcot-Neumann, are found 
in the stools. 

Cellular ele?Jie?its are also found, e. g., leucocytes in in- 
testinal catarrh, especially in ulcerations. Red blood 



66 CLINICAL DIAGNOSIS. 

corpuscles are rarely seen in intestinal hemorrhage, as 
they are generally already destroyed. Cylindrical epi- 
thelial cells are often found in intestinal catarrh, and are 
often seen in the process of disappearance. Pavement 
epithelium in the stools comes from the anus. 

Micro-oi'ganis7ns occur in large numbers in the stools. 
The proof of the presence of the bacillus of tuberculosis 
and of Asiatic cholera is of diagnostic importance. The 
presence of the latter can be proved by further culture 
only. 

For the account of the animal parasites see Chapter 
XI., and for the analysis of the concrements of the gall 
and faecal stones see Chapter XIII. 



CHAPTER IX. 

THE URINE-PRODUCING SYSTEM. 

The Genito-Urinary Organs. 

The kidneys lie on both sides of the vertebral column 
from the level of the twelfth dorsal to the first to third 
lumbar vertebra. The right kidney borders above on 
the liver, the left on the spleen. The lower and outer 
borders of the organs are determined by percussion. 
The outer border is about 10 cm. [4 inches] external to 
the spinous processes (renal-hepatic and renal-splenic 
angle). The kidney dulness may be absent in disloca- 
tion of the kidney (wandering kidney is generally on the 
right side), or it may be increased by tumors of the kid- 
ney (hydro-nephrosis, neoplasms and echinococcus of 
the kidney). The latter may generally be felt by press- 
ing deeply into the anterior abdominal walls. 

The urinary bladder when filled may generally be felt 
and percussed as a round tumor in the median line 
above the symphysis pubis. 

The Urine. 

The products of decomposition of fat and of the carbohydrates 
leave the body essentially as carbonic acid and water by the lungs ; 
the last products, however, of the decomposition of the albumen 
pass out almost exclusively in the form of urine. Therefore an ex- 
amination of the urine gives us information, qualitative and quanti- 
tative, as to the passing out of the products of decomposition of the 
albumen. 

67 



68 CLINICAL DIAGNOSIS. 

The amount of urine excreted in health by men is 
about 1,500 to 2,000 ccm. [40-60 ounces], and by women 
1,000 to 1,500 ccm. [30-40 ounces] in a day. Under 500 
ccm. [15 ounces] and over 3,000 ccm. [90 ounces] is 
almost always pathological. 

A lasting increase in the amount occurs in diabetes mellitus and 
insipidus, in granular atrophy of the kidney, in pyelitis as well as in 
absorption of collections of fluid in the body. A decrease of urine 
occurs in fever, in acute and chronic parenchymatous nephritis, in 
cholera, in profuse sweating, as well as in the formation of exuda- 
tions and transudations ; further in valvular heart disease, and in 
other diseases with lowering of the blood pressure. 

The specific gravity varies in healthy individuals under 
ordinary conditions of nourishment, between 1,015 and 
1,025. A decrease (1,002) occurs in renal disease and in 
diabetes insipidus, an increase (1,060) in diabetes mel- 
litus and in fever. 

The specific gravity is measured by dipping the dry urinometer 
into the fluid cooled to the surrounding temperature, and then read- 
ing off the amount at the level of the fluid. 

If the two last figures of the specific gravity be multiplied by the 
coefficient of Haser 2.33, the result is approximately the amount (in 
grams) of solid substances in 1000 ccm. [30 ounces] of urine. From 
this the amount for the 24 hours may be calculated. Thus if the 
amount of urine be 2000 ccm. [60 ounces], and the specific gravity 
1012, then there are 55.92 grams [about 530 grains] of solid sub- 
stances in the urine. 

2.33 X 12 = 27.96 X 2 = 55.92. 

The 7'eaction of normal human urine is acid, especially 
on account of the acid phosphates of sodium (NaH 2 
P0 4 ) contained in it. 

The acid reaction of the urine is greater in proportion 
to its concentration — e. g., after strong perspiration, as 
well as in increased albuminous metabolism, as in fever. 



THE URINE-PRODUCING SYSTEM. 69 

The reaction is slightly acid, neutral, or alkaline in very 
dilute urine, and after taking the alkalies of carbonic 
acid or vegetable acid (the latter being reduced in the 
body to carbonic acid, as in a vegetable diet) ; again, 
when much hydrochloric acid of the stomach has been 
removed from the organism by habitual vomiting or by 
lavage. Also in the rapid absorption of exudations and 
transudations, the reaction of the urine is less acid ; 
whereas in the collection of this fluid, the urine is strongly 
acid. 

As soon as the urine becomes neutral or alkaline, the 
earthy phosphates are precipitated (basic phosphate of 
lime and magnesia Ca 3 [P0 4 ], and Mg 3 [P0 4 ] 2 ) ; also 
occasionally the carbonates of the alkaline earths fall to 
the bottom as a white flocculent sediment. This is dis- 
solved at once by the addition of acids, but not by heat- 
ing nor by adding alkalies (which distinguishes it from 
uric acid sediment). Slightly acid or neutral urine be- 
comes sometimes cloudy on heating, by separating the 
earthy phosphates. This cloudiness disappears on add- 
ing acids, or on cooling off — a thing which distinguishes 
it from the cloudiness of albumen. 

If the urine be decomposed by the presence of bacteria in 
the bladder (cystitis), or after it has been passed, the re- 
action is also alkaline (the alkaline urine fermentation) 
from the carbonate of ammonia formed from the urea. 
The ammoniacally decomposed urine has a bad odor 
and develops hydrochlorate of ammonia by holding over 
it a glass rod moistened with hydrochloric acid. "While 
there is a moderate amount only of the crystals of 
ammonio-magnesian phosphates (Mg NH 4 P0 4 ) in the 
sediment of non-decomposed alkaline urine, these crys- 
tals (coffin-lid crystals) appear in abundance in ammonia- 



JO CLINICAL DIAGNOSIS. 

cally decomposed urine, which may also contain in addi- 
tion the thorn-apple-shaped crystals of the urate of 
ammonia. The blue mark on litmus paper from ara- 
moniacal urine disappears on letting the paper dry in the 
air, while the blue spot from urine whose alkalinity is 
due to a fixed alkali remains after the litmus paper is 
dry. If there is a sediment of pus in the urine, it has a 
crumbly appearance if the urine is acid ; while in alkaline, 
decomposed urine, this sediment forms itself into balls 
and mucous, thick thread-like clumps. 

Normal Constitutents of the Urine. 

Urea (U), NH 2 CO NH 2 , is freely soluble in water 
and alcohol. The daily amount excreted by healthy in- 
dividuals is between 20-40 grams [300-600 grains] ; it is 
increased in an albuminous diet and in an increased loss 
of the albumen of the body — e. g., in diabetes mellitus 
(to more than 100 grams [1,500 grains] ), in fever (to 50 
grams [750 grains] ), in phosphorous poisoning, and in 
dyspnoea. It is decreased in inanition (to 9 grams [135 
grains] ), in a diet poor in nitrogen ; further, in uraemia, 
and in acute yellow atrophy of the liver. 

The urea is changed by bacteria or through the effect 
of strong alkalies into the carbonate of ammonia, by 
taking up water, thus : 

NH, CO NH 2 + 2 H s O = NH 4 C0 3 NH 4 . 

If urea be heated dry, biuret is formed, and its watery 
solution added to caustic potash and a drop of a sul- 
phate of copper solution, gives a violet color (biuret re- 
action.) 

To show the presence of urea (e. g. t in sputa, vomitus, transuda- 
tions, etc.), the evaporated fluid is extracted with alcohol, filtered, 
the filtrate evaporated, the residue dissolved in a little water and 




THE URINE-PRODUCING SYSTEM. J\ 

concentrated nitric acid added to it. After standing in the cold a 
little while, the hexagonal crystals of nitrate of urea appear. 

Since the nitrogen which appears in the urine, and which comes 
from the changes of the albumen in the Fig. 22. 

organism, not only appears as tirea, but 
also in other nitrogenous compounds, at 
least in relatively small amounts, it is better 
to find out the entire amount of nitrogen 
in the urine, instead of the amount of urea, 
in order to draw conclusions as to the 
changes of albumen in the organism. As 
to the exact methods of determining the 
nitrogen see the text-books. 1 

In order to find out approximately the Nitrate of Urea. 

amount of nitrogen in the urine, the following modification of the 
titration method of Liebig by Pniiger is sufficient : 

A row of thick drops of soda paste (a mixture of soda and water) 
is dropped on a glass plate which has a black background, then 10 
ccm. [2-3 drachms] of urine are measured out with a pipette and 
dropped into a beaker glass, then let I ccm. [15 drops] of a nitrate 
of mercury solution 2 drop from a graduated burette upon each one 
of the drops of soda paste. If the point of contact of the two drops 
continue white, the nitrate of mercury should be added until it turns 
yellow and until the yellow does not disappear on stirring. Then 
the amount of the nitrate of mercury used is to be multiplied by 0.04 
in order to obtain the percentage of nitrogen in the urine. If, for 
example, 13 ccm. [| ounce] of the nitrate of mercury solution be used 
before the yellow color appears, the result is 13 X 0.04 = 0.52 % N. 

Uric Acid, C 5 H 4 N 4 3 . — The daily amount passed 
is between 0.2 gram [3 grains] and 1.0 gram [15 grains], 

1 Neubauer und Vogel, Anleitung zur qualitativen und quantitati- 
ven Analyse des Harns ; Salkowsky und Leube, die Lehre vom 
Ham ; Lobisch, Anleitung zur Harnanalyse ; Hoppe-Seyler, Hand- 
buch der physiologisch- und pathologisch-chemischen Analyse, and 
many others. 

2 A litre [30-32 ounces] of mercurial nitrate solution contains 
71.48 grams [1,070 grains] of mercury. For its preparation, see the 
text-books just mentioned. 



72 



CLINICAL DIAGNOSIS. 



and it generally decreases and increases with the varying 
amount of urea. It is considerably increased m leu- 
caemia. During an attack of gout it is said to decrease, 
and after the attack to increase. 

Uric acid is normally present in the urine as neutral 
urate of sodium, which is freely soluble in water. In 






Fig. 23. 





Comb-shaped and Whetstone-shaped Crystals of Uric Acid. 

concentrated and strongly acid urine, in fever and after 
severe sweating, the acid urate of sodium is present after 
Fig. 24. the urine has stood for some time in the 
*•*&<$$? cold. This acid urate of sodium is easily 
f ^b» soluble in warm urine, and only with diffi- 
"jf* culty soluble in the cold. Red-colored, 
Brick-dust sediment brickdust sediment is precipitated (by 
monia. Urate ° f Am " uroerythrin), which is re-dissolved on heat- 
ing, or on adding caustic potash. Urate of ammonia is 
found as thorn-apple-shaped crystals in Fig. 25. 

decomposed urine. Free uric acid, which 
is almost insoluble in water, often ap- 
pears in strongly acid urine, especially 
after long standing. It forms at the 
bottom of the vessel a heavy, hard, red, 
crystalline powder, which under the 2EKtf the Urate ° £ 
microscope shows crystals of the shape of whetstones, 
combs, casks, and spear-heads. 





THE URINE-PRODUCING SYSTEM. 73 

In order to test for uric acid, some of the substance (sediment or 
concrement of the urine) is mixed upon the top of a porcelain cruci- 
ble with a few drops of nitric acid, and slowly evaporated. An 
orange-red spot is formed, which turns purple on adding ammonia, 
and blue on the addition of caustic potash. This is called the 
murexide test. 

Oxalic acid, (COOH) 2 . — The daily amount is as much as 0.02 [}-} 
grain], and it appears in the sediment as oxalate of Fl S- z6 - 
lime (insoluble in acetic and soluble in hydrochloric 
acid) in very small, shining, octahaedral crystals (en- 
velope shape), or in needle shape. 

Sidpho-cyanide of potash, SCNK. — The daily 
amount excreted is 0.05 gram [Jg- grain]. It gives, Envelope -shaped 
with diluted solution of the chloride of iron, a red color, oxafate ofLime. 
which does not disappear on adding hydrochloric acid, and which is 
soluble in ether. 

Hippuric acid, C 9 H 9 N0 3 . — The daily amount excreted is o. 1— 1.0 
gram [i4— 15 grains]. It is formed in the kidneys by the combina- 
tion of benzoic acid and glycocoll, and often appears in needle- 
shaped or rhombic prisms, which are like the triple phosphates, but 
are insoluble in acetic acid. 

Xanthine, C 5 H 4 N 4 2 , and Hypoxanthine, C 5 H 4 N 4 0. — The 
latter is found in the urine in leucaemia. 

Creatinine, C 4 H-N s O. — The daily amount, 0.5-1.0 gram [7-15 
grains], is increased in an abundant meat diet and in increased 
metabolic muscular change, and decreased in inanition and con- 
valescence. 

Aromatic oxi-acids, as paroxyphenol acetic acid, give like the phenol 
group a red color when treated with Millon's reagent. 

The Phenols : Cai-bolic acid, C G H 5 OH, Hydroquitione, C 6 H 4 
(OH) 2 , Cressol CH s C G H G OH. — The phenols exist in the urine in 
the form of the sulphates, as the so-called ethereal sulphates. An 
increase of this denotes decomposing processes in the organism. 
To detect the phenols in the urine, to 100 ccm. [3 ounces] of urine 
5 ccm. [ij drachms] of concentrated sulphuric acid are added, and 
the whole distilled in a retort. Bromine water is then added to the 
distillate, and if carbolic acid is present, there is formed a yellow- 
white precipitate of tri-bromo-phenol. 

Indican (indoxyl sulphate of potassium), C 8 H 6 NO 



74 CLINICAL DIAGNOSIS. 

S0 3 K. — Indol, the result of the decomposition of al- 
bumen in the intestinal canal, or of putrid suppuration, 
is re-absorbed and oxydized in the organism to indoxyl, 
which, in the urine, combines with sulphuric acid and 
passes out as the indoxylsulphate of potassium (indican). 
This latter splits up on adding concentrated hydrochloric 
acid and the chloride of lime (as an oxydizer), and forms 
indigo blue. Indican is increased by an abundant meat 
diet ; further, in putrid suppuration, in diseases of the 
stomach and intestines, in abnormal putrefaction of the 
ingesta, and is most increased in intestinal obstruction. 
From the amount of indican in the urine a conclusion 
may be drawn as to the intensity of the processes of the 
decomposition of albumen in the intestinal canal. 

In order to test for indican, to a small quantity of urine, \ of its 
volume of a 10 % solution of the acetate of lead is added, by which a 
number of disturbing substances are precipitated, and removed by 
nitration. To the filtrate is then added an equal part of hydrochloric 
acid and one or two drops of a concentrated solution of calcium 
chloride, which is one half diluted with water. The chloride-of- 
ealcium solution is added drop by drop until a blue color appears. 
Too much chloride of calcium hinders the formation of the indigo. 
A few ccm. of chloroform are then added, and the whole shaken, 
which brings out the indigo. 

Inorganic Constituents of the Urine. 

If ydroc Marie acid HC1 is present principally combined 
with sodium as common salt. The amount of sodium 
chloride in the urine is about one half the amount of urea 
present, /. e. y between n and 15 grams [150 and 225 
grains]. It depends principally upon the amount of salt 
taken with the food. It is lessened in inanition and in 
fever, especially in pneumonia. Indeed, in the latter dis- 
ease there is often so little present in the urine that the 



THE URINE-PRODUCING SYSTEM. 75 

addition of a nitrate of silver solution causes a slight 
cloudiness only, while normally the chloride of silver 
is precipitated in large quantities. The chlorides are 
increased (to as much as 55 grams [825 grains]) dur- 
ing a rapid re-absorption of exudations. 

Sulphuric ««V/H 3 S0 4 . The daily amount excreted is 
from 2.0 to 2.5 grams [J— | drachm], and it appears partly 
as ethereal sulphuric acid in combination with phenol, 
indoxyl, etc., and partly as " preformed " sulphuric acid. 
The proportion of the former to the latter kind of sulphu- 
ric acid is about as 1:10. In carbolic acid poisoning, how- 
ever, the entire amount of sulphuric acid present may be in 
combination with carbolic acid. In order to test for the 
ethereal sulphuric acids the urine is first rendered slightly 
acid with acetic acid and then barium chloride is added 
in excess, by which the preformed sulphuric acid alone is 
precipitated and may then be removed by filtration. 
The filtrate is then treated with concentrated hydrochlo- 
ric acid and then heated. By decomposition of the ethe- 
real sulphuric acids a precipitate of barium sulphate is 
formed from which the amount of ethereal sulphuric acid 
may be determined. 

Phosphoric acid H 3 P0 4 . The daily amount excreted 
is 2.5-3.5 grams [f-i drachm] of which two thirds are 
combined with alkalies and one third with alkaline 
earths (lime and magnesia). The daily amount of the 
earthy phosphates is 1.2 grams [iS grains]. 

Carborac acid C0 2 is present in human urine in very 
small quantities and is more abundant after taking fruit 
and vegetable food, after many drugs, as well as in 
decomposed urine. When large quantities of the car- 
bonates are present the urine effervesces on the addition 
of acids, and causes a white deposit on a glass rod mois- 



7 6 



CLINICAL DIAGNOSIS. 



tened with baryta water and held over the mouth of the 
test tube. Carbonate of lime is present in the sediment 
as small spherical and biscuit-shaped [dumb-bell crystals] 

Fig. 27. Fig. 28. Fig. 29. 





Spherical and Biscuit- Neutral Phosphates of Coffin-lid Crystals of the Am- 

shaped [dumb-bell] Lime. monio-Phosphate of Magnesia. 

Crystals of the Carbon- 
ate ot Lime. 

bodies which dissolve with the formation of bubbles on 
the addition of acids. 

Sodium. The daily amount excreted is 4-6 grams 
[i-i|- drachms], in form of sodium oxide Na 2 0. Potas- 
sium. The daily amount excreted is 2-3 grams [30-45 
grains], in form of potassium oxide K 2 0. During fever 
the amount of sodium decreases, while the amount of 
potassium is 3 to 7 times as great. Ammonia NH 3 is 
present in unfermented urine in small quantities only, 
(0.6-0.8 gram [10-12 grains]). It is much decreased in 
many cases of diabetes. Calcium. The daily amount 
excreted is 0.16 gram [2 J- grains], in form of CaO. 
Magnesium. The daily amount excreted is 0.23 gram 
[$i grains], in form of MgO. 

The sulphate of calcium (gypsum) is present in the 
sediment in form of fine oblique prisms and needles, 
which are not soluble in acetic acid. Neutral phosphate 
of calcium is present in form of wedge-shaped crystals 
which unite to form rosettes. The ammonio-magnesian 
phosphates, or triple phosphates, occur as shining coffin- 
lid-shaped crystals. The two last of these crystals men- 
tioned are soluble in acetic acid. 



THE URINE-PRODUCING SYSTEM. J J 

Iron is present in the organism in combination and 
therefore appears in the ash of urine only. 

Pathological Constituents of the Urine. 

Albumen (serum albumen and serum globulin). In order 
to make use of the following tests, the urine should be 
clear, and filtered if not clear. 

I. Heat Test. — The urine is heated to the boiling point in a test- 
tube, and then one or two drops of diluted acetic acid should be 
added. Instead of the acetic acid, nitric acid may be used, in 
which case ten to twenty drops should be added. If the cloudiness 
caused by heating be dissolved by the acid, then it was not caused by 
albumen, but by the phosphates and carbonates of lime and magnesia 
which are freely soluble in the acids. If the cloudiness remain, or if 
it appear on the addition of acid, it is caused by albumen. 

A cloudiness often appears after adding acetic acid to the urine 
when it is warm, or when it has cooled off. In this case it is not due 
to mucin, but to albumen. 

If the precipitate of albumen be taken from the filter and its vol- 
ume approximated after three to twelve hours, an approximate 
result, as to the amount per cent, of albumen in the urine may be 
obtained. When the amount of albumen is 2 % to 3 %, the whole 
fluid is completely coagulated. When there is 1 % of albumen pres- 
ent, the coagulum in the test-tube reaches half way up to the level 
of the urine. 

When 0.5 %, J- the way up. 
" 0.25 £, i " " " 

U.J. jc, 10 

' 0.05 £, the curved part of the tube is barely filled with albu- 
men, and when there is less than 0.01 % present, there is a slight 
cloudiness, but no precipitate. 

II. Heller s Test. — The test-tube containing the urine is held ob- 
liquely and concentrated nitric acid is poured slowly down the side 
of the tube so as to flow below the urine. If albumen be present, 
there is formed a sharply defined ring-shaped cloudiness at the point 
of contact between the urine and the acid. Besides albumen, a pre- 
cipitate in very concentrated urine may be caused by the presence cf 



78 CLINICAL DIAGNOSIS. 

urea, in which case the ring is higher and not so clear. A cloudi- 
ness may also be caused by nitrate of urea, and in this case the pre- 
cipitate is crystalline and does not appear until after standing a long 
time. A cloudiness may occur from the resinous substances, as after 
taking copaiva, styrax, turpentine, etc., but in this case the precipi- 
tate is dissolved, after cooling, in alcohol. The ring of albumen 
may be colored blue or green by indigo, or by the coloring matter of 
the gall. 

III. Test with Acetic Acid and Ferrocyanide of Potassium in the 
cold. — If to some urine three to five drops each of acetic acid and 
a 10 % solution of ferrocyanide of potassium be added, there occurs 
a precipitate from the presence of albumen or hemialbumose. If 
the urine be taken in very small quantities, the precipitate appears 
only after a few minutes. 

IV. Biuret Test. — The urine is first to be made alkaline with 
caustic potash, and then 1-3 drops of a diluted solution of sulphate 
of copper are to be added, and if albumen, hemialbmnose, or peptone 
be present, a reddish violet solution is formed. 

[V. Picric Acid Test. — A delicate and convenient test used long 
ago in Germany and rediscovered in 1882 by George Johnson. The 
dry acid may be dissolved in the urine, or a saturated solution may 
be used, into which the urine should be slowly dropped, and if albu- 
men is present a cloudiness appears at once.] 1 

For the quantitative determination of albumen, see Chapter X. 

Hemialbumose (Propeptone) is an intermediate state be 
tween albumen and peptone. This is not precipitated 
by heating, but by nitric acid, acetic acid, and ferro- 
cyanide of potassium, as well as by acetic acid and so- 
dium chloride. All these precipitates have the property 
of dissolving on heating and reprecipitating on cooling. 

To test for hemialbumose it is necessary, first, to remove the albu- 
men. For this purpose, to the urine (or to any other fluid to be ex- 
amined, as the contents of the stomach) 5 to 10 drops of acetic acid 
and \ of its volume of a concentrated salt solution are added, and the 
whole heated. Then the albumen will be precipitated and should 
be removed while hot by filtration, while the filtrate is allowed to 
cool off. If a cloudiness now arise on the addition of salt solution 

1 v. Appendix. 



THE URINE-PRODUCING SYSTEM. 79 

to the filtrate then hemialbumose is present. If too much salt solu- 
tion be added, the precipitate of hemialbumose cannot be redissolved 
by heat. 

Peptones are present in the urine principally in the ab- 
sorption of pus and exudations (pneumonia, empyema, 
abscesses and puerperal fever, etc.) They are not pre- 
cipitated on heating, nor with nitric nor acetic acid, nor 
with ferro-cyanide of potassium. They a^e tested for 
with the biuret test after the albumen and hemialbumose 
have been removed or proved absent. 

10 ccm. [2! drachms] of a concentrated solution of sodium acetate 
and a few drops of a solution of iron chloride are added to 500 ccm. 
[1 pint] of urine until there results a permanent red color ; then a 
caustic potash solution is dropped carefully into this mixture until 
it is slightly acid or neutral, and the mixture heated. After it has 
cooled off and been filtered, the filtrate, which ought to be entirely 
free from albumen, is subjected to the biuret test. 

Blood. — We speak of hsematuria when the blood color- 
ing matter is present in the urine in combination with 
the blood corpuscles ; of hsemoglobinuria when the blood 
coloring matter is in solution without there being blood 
corpuscles in the sediment. The latter occurs when 
the blood corpuscles are dissolved by some agent (after 
poisoning, cold, etc.), and the haemoglobin becomes free. 

Urine containing blood-colori?ig matter is either bright red with a 
greenish iridescence (resembling meat juice) from the presence of oxy- 
hemoglobin, or it is a dark brownish-red from the presence of meta- 
haemoglobin. The latter differs from oxy haemoglobin by its being 
recognized in the spectroscope as a dark absorption line in the red 
and a paler one between the green and blue near both the oxyhemo- 
globin lines. 1 

1 The spectroscopic examination may be made with the pocket 
spectroscope. The urine is held in a tube before the slit in the in- 
strument. 



8o CLINICAL DIAGNOSIS. 

Besides, the spectroscopic test blood-coloring matter may also be 
recognized by the following tests : 

Heller s Test. — If the urine be heated with caustic potash, the 
earthy phosphates in precipating take the coloring matter of the 
blood with them, and appear reddish brown instead of white. 

Gnaiac Test. — About I ccm [15 drops] of a freshly made tincture 
of guaiac and the same amount of resinous turpentine oil are added 
to some urine and well shaken. If blood be present the mixture 
turns blue after a few minutes. Instead of turpentine oil, Huhner- 
feld's mixture x may be used. 

The smallest amount of blood which can no longer be recognized 
by one of these methods may be looked for by examining the sedi- 
ment microscopically for blood corpuscles. 

Coloring matter of the bile. In urine there is present 
either the actual coloring matter of the bile (bilirubin) 
which is changed by oxydation into green (biliverdin), 
violet, red, and yellow (choletelin), or hydro-bilirubin 
(urobilin), which originates from a reduction of the col- 
oring matter of the gall and blood. Urine containing 
bilirubin is of a beer-brown color and has a yellow foam 
on shaking. On being shaken with chloroform the bili- 
rubin becomes gold-yellow and is taken up by the chlo- 
roform. 

Bilirubin is tested for by the Gmelin test. A few drops of fu- 
ming nitric acid are added to concentrated nitric acid until a slight 
yellow is observed. This mixture is then poured into a vessel con- 
taining urine in such a way that the acid passes down the side of the 
glass under the urine. Then there is formed at the point of contact 
of the acid and the urine, a colored ring which passes from green 
through violet to red and yellow. A blue ring alone may be caused 

1 Glacial acetic acid, 2.0 ccm [30 drops]. 
Distilled water, 1.0 ccm [15 drops]. 
Oil of turpentine, 
Absolute alcohol, 
Chloroform, — of each 100.0 ccm [3 ounces]. 



THE URINE-PRODUCING SYSTEM. 8[ 

by indigo, a reddish-brown one by hydrobilirubin and other substan- 
ces. 

If a solution of iodine in iodide of potash be added to the urine 
containing bilirubin, it becomes a green (biliverdin). 

Hydrobilirubin is tested for by adding to urine 2-5 drops of a 
10 % solution of the chloride of zinc, and afterwards enough ammonia 
to redissolve the precipitated oxide of zinc. If a green fluores- 
cence is observed (by looking at the test-tube against a dark back- 
ground) in the fluid filtered from the precipitated phosphates, hydro- 
bilirubin is present. Instead of the chloride of zinc and ammonia, 
iodine-iodide of potash and caustic potash may be used. In the 
spectroscopic examination of urine containing hydrobilirubin (even 
after adding the chloride of zinc and ammonia), it may be recognized 
by an absorption line between the green and the blue. 

Gallic acids are found by P ettenkoffer s test : A grain cf cane 
sugar is added to the fluid and the whole is evaporated with gentle 
heat on the cover of a porcelain crucible with a drop of concentrated 
sulphuric acid. If the gallic acids are present the fluid becomes 
purple. The same reaction may be caused by other substances 
(albumen, fatty acids, etc.), so that the gallic acids should first be 
extracted from the urine. For the procedure necessary (as evapo- 
rating, extracting with alcohol, precipitating with baryta and ex- 
tracting the cholalate of baryta with warm water), see the text-books. 

Grape Sugar (Dextrose) C G H 12 O c is fermented by 
yeast to alcohol and carbonic acid (=z 2C 2 H 5 OH -J- 
2C0 2 ), shows a brown color when heated with caustic 
potash, is capable of reducing, and turns the plane of 
polarized light to the right. 

I. To make the fermentation test, a test-tube or eudiometer tube 
is first half filled with mercury, and the same amount of urine is 
added, only leaving enough room for a little yeast. The air bubbles 
are removed from the opening of the tube, which is then closed by 
the finger, and dipped upside down under mercury, and left there at 
a temperature not over 30 C [86° F], The presence of grape sugar 
soon causes a development of gas. In order to show that the gas is 
carbonic acid, some caustic potash is introduced through a curved 
pipette into the tube, and by this the carbonic acid is absorbed. 



82 CLINICAL DIAGNOSIS. 

This determines the presence of grape sugar. Much more conven- 
ient are the so-called fermentation tubes} A piece of yeast as large 
as a pea is introduced into one of the tubes and urine is so added 
that no air enters into the vertical branch of the tube. For the 
sake of greater certainty a second tube with a dextrose solution and 
yeast, and a third tube with normal urine and yeast, may be also 
used. If the result of the second test is positive, this shows that 
the yeast is effective, and if the result of the third test is negative, 
it shows that the urine contains no sugar. 

By determining the specific gravity of urine both before and 
after fermentation (after 24 hours at the temperature of the 
room), the approximate amount of grape sugar may be obtained. 
The urine is made to ferment with yeast in a long-neck bottle, the 
opening being covered with a watch glass to prevent evaporation. 
After 24 hours the specific gravity of the filtered urine is taken at 
the same temperature. The difference in the specific gravity before 
and after the fermentation is read from the urinometer, each degree 
of which corresponds to 0.219 % of sugar. Thus urine which before 
the fermentation had a specific gravity of 1040, and after, the specific 
gravity of 1020, contains 4.38 % of sugar. 

II. Moore's Test. If urine containing sugar be heated a few 
minutes with one third its volume of a concentrated caustic potash 
solution, it turns brown. This test is reliable only when the brown 
color is very intense, for sugar to the amount of 0.5 % cannot thus be 
found. With 1 % of sugar the color becomes canary yellow, 2 % am- 
ber yellow, 5 % the color of Jamaica rum, and 7 % it becomes blackish 
brown and non-transparent. 

III. Reduction Tests. 

(a) Trommers Test. — To a quantity of urine, one third its volume 
of a caustic potash or soda solution is added, and then 1-2 drops of a 
diluted (5-10 $) sulphate of copper solution. If the bright blue- 
colored precipitate of hydrated copper oxide remains undissolved 
and flocculent on shaking, no sugar is present. In the presence of 
sugar, glycerine, tartaric acid, ammonia, or albumen the hydrated 
cupric oxide dissolves, giving the urine a sky-blue color. The 
sulphate of copper solution should be added drop by drop until there 

1 To be had of Hildenbrand in Erlangen, and Dr. R. Muenke in 
Berlin, N. W. , Luisenstrasse, 58. 



THE URINE-PRODUCING SYSTEM. 83 

is only a small part left undissolved on shaking the tube. If this 
mixture be then heated the presence of sugar will cause, before the 
boiling point is reached, a yellow-red precipitate of cuprous oxide 
(Cu 2 0), formed by the grape sugar taking oxygen from the cupric 
oxide (CuO). If the fluid change color without forming a precipitate, 
or if the latter be not formed until the urine has cooled off, then the test 
is not convincing, since other reducing substances (uric acid, creatinin, 
etc.) hold the cuprous oxide in solution. Exceptionally reducing 
substances appear in the urine from medicines taken (turpentine, 
chloral hydrate, chloroform, benzoic acid, salicylic acid, camphor, 
copaiva, and cubebs). It is generally a more certain test to let the 
urine stand for 24 hou:s, cold, after adding the substances, instead of 
heating it. If then a yellow precipitate of cuprous oxide appear, it 
can be caused by sugar alone. 

(0) Test with Fehling's solution. — Fehling's solution consists of 

Crystalline sulphate of copper 34.639 [520 grains]. 
Neutral tartrate of potash 173.0 [5^- ounces]. 
Officinal caustic soda solution 100. o [3 ounces]. 
Distilled water enough to make 1000.0 [30 ounces]. 

One ccm. [15 drops] of this is exactly reduced by 0.005 gram 
[yg- grain] of grape sugar. Two ccm. [30 drops] of this fluid are put 
into a test tube, diluted with an equal amount of water and heated. 
In case the formation of the oxides takes place, which would make 
it unfit for use, a few ccm of urine which have been previously 
heated in another test-tube are added to this. If grape sugar be 
present, a yellowish-red precipitate is formed. 

In order to approximately determine quantitatively the amount cf 
grape sugar present, the trituration method of Fehling may be car- 
ried out on a small scale. Two ccm. [30 drops] of Fehling's solution 
(corresponding to 0.01 gram [| grain] of sugar) are measured off in a 
large test-tube and diluted with about ten times its volume of water and 
heated. By means of a dropper 1-3 drops of urine are then added, 
and the whole is heated, observing whether the fluid still shows a 
blue color on holding it to the light. Is this the case, then a few 
more drops are added, and it is again heated and again observed and 
then watched until the last trace of blue has just completely dis- 
appeared, showing that all the cuprous oxide. has been reduced. We 
know that in the urine there is exactly o.ot gram [-J grain] of sugar, 



8 4 



CLINICAL DIAGNOSIS. 



and counting 20 drops to 1 ccm. we can calculate the percentage of 
sugar present. In order to save the time and trouble of making such 
calculation at every examination, the following table will be found 
convenient. It is better to dilute tne urine four or five times in a 
graduated glass. 



Drops = 


% Sugar. 


Drops = 


% Sugar. 


Drops = 


% Sugar. 


I 


20 


10 


2.0 


25 


0.8 


2 


10 


11 


1.8 


30 


0.6 


3 


6.6 


12 


1.6 


40 


0-5 


4 


5 


13 


i-5 


50 


0.4 


5 


4 


14 


1.4 


60 


0.3 


6 


3-3 


15 


1-3 


70 


O.28 


7 


2.8 


16 


1.2 


80 


0.25 


8 


2-5 


18 


1.1 


go 


O.21 


9 


2.2 


20 


1.0 


100 


0.20 



(c) Bottger's Test. — The urine is made alkaline by saturating it 
with sodium carbonate in substance, adding a pinch of the subnitrate 
of bismuth (N0 3 BiOH 2 ) and heating it a few minutes. Or the urine 
may be heated with ■£$ of its volume of Nylander's solution. This 
solution consists of neutral tartrate of potash 4.0 grams [1 drachm], 
10$ solution of caustic soda 100 ccm. [3 ounces], to which are 
added, subnitrate of bismuth 2.0 grams [30 grains] while warm, 
and the whole to be filtered after cooling off. In the presence of 
grape sugar a brown or black color is formed, due to the metallic 
bismuth. 

(d) Mulder s Test. — The urine is first made alkaline with carbon- 
ate of sodium, and then a solution of indigo carmine (sulphate of 
indigo) is added until the urine turns blue. On heating, the indigo 
blue is reduced by the grape sugar present to indigo white, and on 
exposure to the air again, turns blue. 

IV. Test with phenylhydrazin. — Two pinches of phenylhydrazin 
and four pinches of the acetate of sodium are put into a test-tube, 
which is then half filled with water and heated. Then an equal vol- 
ume of urine is added, and the test-tube is heated for 20 minutes 
in a water bath and allowed to cool off. When the urine contains a 
large amount of grape sugar, a yellow crystalline precipitate of 
phenylglucosazone is formed, and when there is only a little grape 



THE URINE-PRODUCING SYSTEM. 85 

suger present the sediment under the microscope shows these crys- 
tals of this form (v. Jaksch). 

V. Polariaztion Test. — The specific angle of grape sugar for yel- 
low sodium light (a) D is 53°. From the degree of deviation a in 
the special case, and the length / of the tube used expressed in 
decimeters, the percentage of grape sugar in the urine may be calcu- 
lated from the formula p = • IO ° 1 

With the presence of substances turning the light to the left, as 
albumen or oxybutyric acid, the determination by polorization is of 
little value ; therefore it is best to ferment the urine and then polar- 
ize it a second time. Dark or cloudy urine should be made clear by 
the addition of ^ its volume of sugar-of-lead solution in a measure 
glass, and the dilution should of course be taken into account. 

Sugar of milk (lactose), C I2 H 22 0„, is present in the urine 
of nursing lying-in women. It has a right rotatory 
power (//) D z= 52.5, and passes over with difficulty into 
alcoholic fermentation and rarely into lactic acid fer- 
mentation. It has the property of reduction. 

Inosite, C 6 H I2 6 , is present in polyuria. It is neither 
fermentable, nor does it possess the power of polariza- 
tion nor of reduction. For its formation see the text- 
books. 

Acetone, CH 3 COCH 3 , is present in urine in febrile 
diseases, in diabetes, in certain forms of carcinoma, and 
in inanition and auto-intoxication. 

To test for the acetones a few drops of freshly-prepared nitro- 
ferrocyanide of sodium are added to the urine, and then a strong 
caustic soda solution, until it is decidedly alkaline. When the 
beginning purple tint turns yellow, I to 3 drops of concentrated 
acetic acid are added, and if the acetones be present a crimson- 
purple color is formed at the point of contact of the acetic acid and 
the mixture (Legal's test). It is better to distill the urine with 
some muriatic acid, and to test the distillate for acetone with 
Lieben's test. According to the latter a few drops of a solution of 
iodine in iodide of potash and caustic potash are added to a few 

1 v. Appendix. 



86 CLINICAL DIAGNOSIS. 

ccm. of the distillate. If the acetone be present, a yellow- white 
precipitate of iodoform appears at once. 

Diacetic acid, CH 3 COCH 2 COOH, is present in the urine 
in many grave cases of the contagious diseases, in grave 
cases of diabetes, carcinoma, and in auto-intoxication. 

If to some urine one or two drops of a solution of the chloride of 
iron be added, a gray or chocolate-colored precipitate of the phos- 
phate of iron appears. If more iron chloride be added, the presence 
of diacetic acid gives the urine a dark Bordeaux-red color (the iron 
chloride reaction of Gerhardt), which disappears at once on adding 
sulphuric acid. If the urine be heated first, then the reaction is 
very slight or not at all. If the urine already made acid with sul- 
phuric acid be extracted with ether, the ether takes up the diacetic 
acid, and may be tested for with iron chloride. Still even this re- 
action disappears in 24-48 hours. A brown-red color of the urine 
with iron chloride does not determine the presence of diacetic acid. 
If the urine be distilled the diacetic acid splits up into acetone and 
carbonic acid, and the acetone may then be determined by Lieben's 
test. 

Diazoreaction (Ehrlich). Sulphodiazobenzole unites 
with different kinds of unknown aromatic substances of 
the urine to form colored compounds. 

To prepare this reagent two solutions are necessary : 

a) Sulphanile acid 5.0 [75 drops]. 

Muriatic acid 50.0 [1^ ounces]. 

Distilled water 1000. o [30 ounces]. 

And 

b) Nitrite of sodium 0.5 [8 grains]. 

Water 100.0 [3 ounces]. 

When ready for use 5 ccm. [75 drops] of solution b) are to be added 
to 250 ccm. [8 ounces] of solution a), and this " reagent " should be 
prepared fresh for every test. Then to equal parts of this reagent 
and urine -} volume of ammonia is added, and shaken up. In cer- 
tain (febrile) diseases the fluid turns red (scarlet, orange, orange- 



THE URINE-PRODUCING SYSTEM. 87 

red), which is especially noticeable in the foam (red reaction). This 
color is noticeable in typhoid fever (from the first week on), some- 
times in relapses, also in grave cases of phthisis pulmonum, pneu- 
monia, measles. The disappearance of this reaction is considered a 
good sign. 

Melaninc. — In the urine of those suffering from melanotic carci- 
noma, melanogen is sometimes present, which forms black clouds of 
melanine on adding concentrated nitric acid or chromic acid to the 
urine. At times the urine is dark from the presence of formed mel- 
anine in the urine. 

Sulphuretted hydrogen, H 2 S, is present principally in decomposed 
urine, as in cystitis. Since it is found in normal urine after long 
standing, only fresh urine should be taken. A few drops of muriatic 
acid are added to the urine in a bottle, and the opening is covered 
with filter-paper which has been moistened with a sugar-of-lead 
solution. If H 2 S be present the moistened paper turns dark from 
the formation of the sulphide of lead. 

Leucine or A midocaproic acid, and Tyrosine or Amido-Hydroparacu- 

maric acid are present in the urine principally in acute yellow atrophy 

of the liver and in 

, r • • Fig. 30. Fig. 31 

phosphorus poisoning. 

Leucine appears in 
yellow globules, which 
have a fatty gloss and 
arc often marked with 
radiating lines. Ty- 
rosine is in the form 

r r- i 11 r Leucine. Tyrosine. 

of line bundles of 

needles or globules. The urine is evaporated to syrupy consistency 

and left in the cold to crystallize, and then examined microscopically. 

Cystine is occasionally present in the sediment in the form of color- 
less shining hexagonal plates. 

Fat is occasionally present as a fine cloudiness and gives the 
urine .a milky appearance (chyluria). This milkiness disappears on 
adding caustic potash and shaking up with ether. 

Test for Drugs. 

Iodine and Bromine. — Freshly made chlorine water or strong 
fuming nitric acid is added to the urine and then shaken with a few 




88 CLINICAL DIAGNOSIS. 

ccm. of chloroform, which is then colored carmine red if iodine 
is present, and brownish yellow if bromine is present. 

Nitric acid. — A brucine solution is added to the urine and the sul- 
phuric acid is allowed to trickle down the side of the glass and at the 
point of contact a red ring is formed. The same reaction may be 
caused by other bodies (as hydrobilirubin). 

Lithium. — The flame reaction or a spectroscopic examination of 
the ash is sufficient. 

Arsenic. — After removing the organic substances with muriatic 
acid and chlorate of potash, the fluid is examined according to 
Marsh's test. 

Lead. — Fresh muriatic acid and chlorate of potash are added 
to destroy the organized substances, the chlorine is driven off, then 
the mixture is filtered off and sulphuretted hydrogen conducted 
through it, and if lead be present a brown color, due to the sulphide 
of lead, is formed. 

Mercury. — To the urine of one day, 10 ccm. [2 drachms] of 
muriatic acid and a small quantity of brass or copper shavings are 
added, and the whole is heated. After 24 hours the urine is poured 
off and the metal washed several times in water made slightly alka- 
line with caustic potash, then washed with alcohol, then with ether, 
and then let dry. The metal is then brought into a long large dry 
test-tube and heated red-hot. If the mercury be present it has 
already amalgamated itself with the copper or brass and the heat 
volatilized it and caused it to be condensed on the cool parts of the 
tube. Now, if fumes of iodine be introduced into the tube the mer- 
cury is changed to the iodide of mercury which appears as~ a 
red tinge, and by careful heating may be condensed to a sharply de- 
fined ring. 

Quinine. — 500 cm. [15 ounces] are made alkaline with caustic 
potash and shaken five minutes with ether. The ether is then 
brought to the surface and evaporated off, and the remainder taken 
up with water and a few drops of muriatic acid. This fluid shows a 
blue fluorescence on adding a drop of sulphuric acid, or, if treated 
with strong chlorine water and concentrated ammonia, it shows a 
green ring. 

Carbolic acid (Phenol C 6 H 5 OH) — When much carbolic acid has 
been ingested the urine becomes greenish brown and turns dark 
when exposed to the air, just as the urine does after taking hydro- 



THE URINE-PRODUCING SYSTEM. 89 

quinone (C 6 H 4 (OH) 2 ), folia uvse ursi, and tar. For the behavior 
of sulphuric acid in carbolic acid intoxication, and the detection 
of carbolic acid, see pages 73 and 75. 

Salicylic acid (Oxybenzoic acid). — The urine turns violet on adding 
chloride of iron. 

Ariipyri;i. — The urine turns red on adding chloride of iron. 

Thallin. — The urine is greenish-brown and turns purple on adding 
iro~ chloride. On shaking up the urine with ether, the unchanged 
thallin is also taken up by it and this turns green on adding the chlo- 
ride of iron. 1 

Kairin. — The urine is greenish brown, turns dark on standing, 
and turns brownish-red on the addition of the chloride of iron. 

Turpentine . — The urine smells of violets and a precipitate is 
sometimes formed on adding nitric acid. 

Tannin. — The urine turns bluish-black on the addition of chloride 
of iron. 

Santonin. — The urine is straw -yellow and turns scarlet on the ad- 
dition of alkalies. 

Rhubarb and Senna (Chrysophanic acid). — The urine turns also red 
on the addition of an alkali, but the color remains permanent, 
while in the case of santonin it soon disappears. On the addition of 
baryta water the precipitate with rhubarb and senna is red, and with 
santonin the nitrate. Ether takes up the color of senna and rhubarb, 
but not of santonin. 

Organic Sediments. 

Leucocytes are present normally in a small number in 
the urine, and in a large amount in inflammation and 
suppuration in any part of the genito-urinary apparatus 
(nephritis, pyelitis, cystitis, gonorrhoea, fluor albus). In 
alkaline urine the pus is of a mucous nature. Red blood 
corpuscles in the urine are generally free from color, and 
in renal hemorrhage are often in the casts. 

The renal epithelium is small, round, or cuboid with a 
vesicular nucleus, and often very full of fat drops. They 
are often arranged in cylindrical form or lie on the tube 
casts adherent to them (epithelial casts). The appear- 

1 v. Appendix. 



go 



CLINICAL DIAGNOSIS. 



® 




ance of renal epithelium in the urine always points to a 
Fig. 32. morbid process in the kidney. When there 
p are numerous fatty degenerated epithelial 
gL.** cells in the urine, it is a sign of chronic par- 
H ,*• ' enchymatous nephritis. 
SSiy 1 SdSS&S The epithelial cells of the bladder, ureters, 
atty tioI? nera " and renal pelvis do not differ from each other 
in appearance. The cells of the superficial layers have 
a polygonal form, those of the deeper layer are somewhat 
round, often with processes 
(pear-shaped), and contain a 
vesicular nucleus. If there 
are many of such cells with 
leucocytes in the urine, it is Deep 
evidence of an inflammatory 
condition of the bladder, ure- 
ters, or renal pelvis. The 
microscopical examination is of no assistance here, but 
we can generally take it for granted that the urine in 
pyelitis is generally acid, and in cystitis generally al- 
kaline. 

The vagina and prepuce possess very long, flat epithelial 
cells like those of the mucous membrane of the mouth. 
The male urethra has cylindrical epithelium. These 
epithelial cells are often found in the suppuration of 
acute gonorrhoea. The gonorrhceal pus is also charac- 
terized by the presence of gonococci (see Chapter XL). 

Casts are effusions into the urinary tubules. They are 
present in all cases of albuminuria, not only in nephritis 
but also in all irritative conditions of the kidneys (icterus, 
the acute contagious diseases, heart diseases, etc). We 
distinguish (1) Hyaline casts, which consist of a homo- 
geneous translucent substance, and possess a very deli- 



Epitheliuiu of the bladder, 
urethra, and renal pelvis. 



THE URINE-PRODUCING SYSTEM. 9 1 

cate contour, which is often scarcely visible. (2) Granu- 
lar casts, having a fine-grained substance, but otherwise 
resembling the hyaline casts. (3) Waxy casts, of a yel- 
low color and greater lustre, with sharply-defined contour, 
and are often irregularly curved and bent. They are 
found principally in chronic nephritis, and point to a 
grave disturbance. (4) Brown casts are present in frac- 
tures, and also in the grave cases of contagious diseases. 
(5) Cylindrical casts are long, irregularly broad, with long 
stripes on them. These are perhaps only mucous threads, 
and are of no diagnostic importance. Very often other 
substances are attached to the casts, especially to the 
hyaline casts, as urates, fat drops, red blood corpuscles, 
leucocytes, and renal epithelium. 

Further, there are found occasionally in the urine 
spermatozoa and cells of neoplasms (cancer, papilloma). 

Micro-organisjns are present in fresh urine in several 
of the contagious diseases (diphtheria, relapsing fever), 
in cystitis, and pyelonephritis (in a cylindrical form), also 
tubercle bacilli in tuberculosis of the genito-urinary tract 
and gonococci in gonorrhoea. 

Animal Parasites : 

(1) Echinococcus cysts and hooklets. 

(2) Embryos of filaria sanguinis : small snake-like 
worms which are exceedingly movable, and are as broad 
as the diameter of a red blood corpuscle, and 0.35 mm. 

[tto inch ] lon S- 

(3) Distomum haematobium whose eggs have on one 
end or on the side a spinous process. The two last 
parasites may cause hematuria and chyluria (z>. Chapter 
XL). 

For the analysis of the urinary concrements see 
Chapter XIII. 



CHAPTER X. 
TRANSUDATIONS AND EXUDATIONS. 

The different serous transudations have a very different 
specific gravity according to their origin. They are in 
the order of their specific gravity ; hydrocele, hydro- 
thorax, ascites, anasarca, and hydrocephalus. 

The serous (inflammatory) exudations have a greater 
specific gravity than the simple transudations of conges- 
tion, and indeed it may generally be taken for granted 
that a fluid, be its origin what it may, is the product of 
an inflammation when its specific gravity exceeds 1018 
(pleurisy, peritonitis), and that it is simply a transudation 
due to congestion when its specific gravity 

in hydrothorax is less than 1015, 
" ascites " " " 1012, 

" anasarca " " " 1010, 

" hydrocephalus" " " 1008.5. 
Now since the amount of ash, extractive matter, etc., 
contained in exudations and transudations varies very 
slightly and the amount of albumen varies very greatly, 
we conclude that the specific gravity is principally de- 
pendent upon the amount of albumen contained in these 
fluids. Therefore from the specific gravity the amount 
of albumen may be approximately determined according 
to the formula of Reuss, 

E = | (S- 1000) -2.8, 
92 




TRANSUDATIONS AND EXUDATIONS. 93 

in which E denotes the amount per cent, of albumen 
sought and S the specific gravity. Accordingly in a spe- 
cific gravity of 1018, 3.95 <f of albumen would be calcu- 
lated. These rules hold good for serous exudations, but 
not for purulent, chylous, and very hemorrhagic exuda- 
tions, nor for those in diabetes, cholsemia, and uraemia. 

In order to determine the specific gravity, the fluid 
should be protected from evaporation and cooled off to 
the surrounding temperature, since fluid at body temper- 
ature has too low a specific gravity ; for every 3 Celsius 
[5. 4 Fahrenheit] increase corresponds to about one de- 
gree of the araeometer less. 

The amount of albumen is determined by diluting a 
known quantity of the exudation (10 ccm. [2 J- drachms] )* 
with ten times its volume of water, heating it to the 
boiling point and adding dilute acetic acid drop by drop 
until the fluid is slightly acid. The precipitate of albu- 
men is then to be collected upon a filter paper which lias 
previously been dried at a temperature of ioo° C. [212 
F.] and weighed, washed with water, then with alcohol 
and ether, the total weight to be deducted from the 
weight of the filter paper. The filtrate should be clear 
and free from albumen, which may be proved by adding 
a few drops of ferrocyanide of potash to the liquid. 

Exudations and transudations have an alkaline reac- 
tion, and deposit, on standing, a more or less abundant 
amount of fibrin. A microscopical examination reveals 
in the coagulum leucocytes and swollen endothelial ceils, 
which often contain vacuoles. 

The contents of the cchinococcus cysts are generally clear, 
neutral, or alkaline, and the fluid has a specific gravity 

1 To determine the amount of albumen in urine 50 or 100 ccm. [1^— 
3 ounces] of urine should be taken. 



94 CLINICAL DIAGNOSIS. 

of 1008-1013, contains little or no albumen, but chloride 
of sodium in large quantities, as well as grape sugar and 
succinic acid. The latter is detected by evaporating the 
fluid, acidifying it with hydrochloric acid and shaking it 
up with ether, and after the evaporation of the ether the 
succinic acid remains as a crystalline mass, whose water 
solution with the chloride of iron forms a gelatinous, 
rust-colored precipitate of succinate of iron. When 
heated in a test-tube the irritating fumes of the succinic 
acid are given off, causing cough. 

On microscopic examination the scolices and ring of 
hooklets are sometimes found. In the older lifeless cysts 
are found crystals of cholesterine and hsematoidine. 

The water of hydronephrosis is generally clear, of a 
specific gravity of 1010-1020, contains mucus, sometimes 
blood and pus, and a varying amount of albumen and of 
urinary constituents. But since these are also found in 
the fluid of the echinococcus the diagnosis of hydro- 
nephrosis should be made only when there is a larger 
amount of urea and uric acid present. Urea is detected 
according to the method on page 70 ; uric acid, by adding 
muriatic acid and examining microscopically the crystals 
formed, or by the murexide test. 

The pear-shaped epithelial cells of the renal pelvis and 
tube casts are also occasionally present. 

The contents of an ovarian cyst are generally mucous, 
tenacious, yellow ; but may be watery, semi-fluid, and 
brown. The specific gravity is between 1003 and 1055 
and generally between 1010 and 1024. The fluid usually 
contains albumen and metalbumen (pseudo-albumen), 
which causes the mucous consistency. This is not pre- 
cipitated by acetic acid (differing in this respect from 
mucin), nor by heat, nor by nitric acid ; but falls into 



TRANSUDATIONS AND EXUDATIONS. 95 

fibrous flakes on adding alcohol. By heating it with the 
mineral acids, a reducing substance is formed. 

To detect the metalbumen the fluid is freed from 
albumen by heat and acetic acid. When metalbumen is 
present the filtrate is opalescent and mucous. It is pre- 
cipitated into white flakes on adding alcohol in excess. 
The flakes are then pressed out and heated with dilute 
muriatic acid (5 <£) until they turn brown ; after cooling 
off they are made alkaline with caustic soda, and a few 
drops of a cupric sulphate solution are added and the 
whole heated. If metalbumen be present there is a pre- 
cipitate of yellow cuprous oxide. 

A microscopic examination occasionally shows the 
presence of cylindrical and ciliated epithelium, and 
sometimes colloid particles. 



CHAPTER XI. 

PARASITES. 

Animal Parasites. 

Cestodes. — The tape-worms represent colonies of indi- 
viduals which consist of a head with hooklets and of a 
larger or smaller number of single individuals called 
proglottides or segments. The eggs which come from 
the matured proglottides (hermaphrodite), if they come 
into the stomach of the right animal, develop in its or- 
gans into a cysticercus. If this cysticercus be taken 
into the intestinal canal, it becomes a tapeworm. 



Fig. 34- 



Fig. 35- 



Fig. 36. 



Fig. 37. 



Fig. 38. 




Segment of Segment of 

Taenia solium. Taenia saginata. 



Segments of 

Bothriocephalus 

latus. 



Egg of Egg of 

Taenia solium. Bothriocephalus 
latus. 



Tcenia Solium is 1-3 metres [yards] long. The head 
is as large as a pin's head, has four suckers, a rostellum 
or proboscis upon which there is a double row of hooks. 



1 Figs. 34, 35 and 36 are from Stein's Entwickelungsgeschichte 
und Parasitismus der menschlichen Cestoden. 

96 



PARASITES. 97 

The matured proglottides have the sexual openings 
on the side and a uterus with 7 to 10 thick lateral 
branches, which subdivide (fig. 34). The eggs are round 
or oval, with a striped shell and an embryo having six 
hooks (fig. 37). The cystic ercus celluloses is about as large 
as a pea, and is found in swine and in man (when the 
eggs are taken into the stomach) under the skin, in the 
muscles, in the brain, eye, etc. 

Teenia saginata or mediocanellata is thicker and 
larger than the former. It has a head with four suckers, 
but no rostellum and no hooks. The proglottides have 
lateral sexual organs and a uterus which subdivides into 
17 to 30 finer branches (fig. 35). The eggs are like those 
of the taenia solium, only somewhat larger. The cysti- 
cercus is smaller, and is found in the flesh of cattle (also 
in deer and sheep). 

The Bothriocephalus latus is 5-9 metres [yards] long, 
and has a lancet-shaped head with two lateral grooves. 
The matured segments are broader than they are long. 
The uterus has a brownish tinge, and is arranged in the 
form of a rosette around the flat sexual openings (fig. 36). 
The eggs are oval and have a cover. The cysticerci are 
found in fish (salmon). 

Taenia nana, taenia flavopunctata and taenia cucumerina (elliptica) 
occur sporadically in man. 

Tamia echinococcus is found in the dog. It is 2\ to 4 
mm. \\—^-§ of an inch] long, has a head with hooklets 
and suckers, and three segments, of which the last one 
only is matured. The cystic form of the echinococcus is 
found in man (in the liver, spleen, kidneys, lungs, etc.). 
It is observed in two forms, as a large echinococcus sac 
filled with daughter cysts, and as an echinococcus multi- 



98 



CLINICAL DIAGNOSIS. 



locularis, which consists of a very large number of 
minute cavities filled with a gelatinous substance and 
with concentrically arranged walls. In the echinococcus 
cysts, heads (scolices) with hooks are sometimes found. 
(For the echinococcus fluid see page 93.) 

Nematodes or Round Worms are bisexual. 

The Ascaris lumbricoides or round worm has its habitat 
in the small intestine. It resembles the rain worm. The 
male is somewhat smaller (150-250 mm. [4—6 inches]) 
than the female (150-250 mm. [4-6 inches]), and its 
head is rolled up. The eggs, which are evacuated in 
large numbers with the stools, have a thick, concentric- 



Fig. 39- 



Fig. 40. 



Fig. 41 



Fig. 42. 




Egg of Ascaris EggofOxyuris Egg of Trichocephalus Egg of Ankylostomum 
lumbricoides. vermicularis. dispar. duodenale. 

ally striped shell, upon which lies a projecting albuminous 
cover (fig. 39). 

The Oxyuris vermicularis or small thread-worm is 
found in both large and small intestines. It often passes 
from the intestine to the anus, causing violent itching in 
that region. The male is 3-5 mm. \\-\ inch] and the 
female 10 mm. [J- inch] long, the former having blunt 
ends, and the latter being pointed. The eggs, which are 
especially numerous around the anus of man, are oval 
and possess a thin shell (fig. 40). 

The Trichocephalus dispar or whip-worm lives in the 
large intestine ; it is 4-5 cm. [1J-2 inches] long, has a 
thread-like head extremity, and a thicker spirally rolled 
body in the male, and a straight slightly curved body in 



PARASITES. 99 

the female. The eggs are yellow in color and shaped 
like a lemon (fig. 41). 

The Anguillula intestinalis (Rhabdonema strongyloides, 
Leuckart) is 2.2 mm. [^ inch] long and lives in the upper 
part of the small intestine. The eggs, which resemble 
those of the ankylostomum duodenale, grow in the intes- 
tine to larvae 0.2 mm. [^ inch] long which are found in 
the faeces as small worms with lively movements. Out- 
side of the body the latter are developed to an interme- 
diate form, the anguillula stercoralis. This belongs to 
the developmental cyclus of the anguillula intestinalis. 

The Ankylostomum duodenale lives in the small intestine, 
and causes anaemia by boring into the intestinal wall 
(e. g., in the anaemia of the St. Gotthard tunnel work- 
men, brickmakers, and miners). The male is 10 mm. [^ 
inch] long and the female 12-18 mm. [|-i inch] long. 
The eggs, which are passed in large numbers with the 
stools, have clear, simply formed shells and an embryo 
which is generally undergoing fission (fig. 42). The eggs 
are developed a few days only, after the passage of the 
larvae from the intestines. 

The Trichina spiralis enters the intestine through trich- 
inosed pork. The male is 1.5 mm. [y 1 ^ inch] long and 
the female 3 mm. [I inch] long. The matured worms 
live in the small intestine and bring forth, after 5-7 days, 
young trichinae, which then bore through the intestinal 
walls, get into the circulation, and fix themselves in the 
course of the next few days in the muscular fibres, where 
they may become encapsuled. Their presence at first 
causes fever. 

The Filaria sanguinis is found in the tropical regions. It causes 
hematuria, chyluria, and disturbances of the lymph circulation. 
The matured form lives in the lymphatic organs of man, and here 



IOO CLINICAL DIAGNOSIS. 

gives rise to a large number of living embryos, which are found 
in the urinary sediment and blood, and indeed in the latter in such 
large quantities that every drop of blood contains several embryos. 
These appear as little worms which move freely, and are surrounded 
by a delicate envelop. They are 0.35 mm. [jj-$ inch] long and as 
broad as the diameter of a red blood corpuscle. 

The Filaria medimnsis may reach 80 cm. [30^ inches] in length 
and |-Its- mm. [^V"~fV incn ] i n breadth. It occurs in the tropics, and 
leads to the formation of abscesses of the skin. 

Trematodes or Flat Worms. 

The Dtstomum hepaticum is 28-32 mm. [1 inch] long, of 
a leaf-like form, with conical-shaped forepart of the body. 
The eggs are very large 0.13 mm. \-fa inch] long (see fig. 
43), and with a cover. 
Fig. 43. Fig. 44. The Dtstomum lanceolatum is small- 

er than the former. It may reach 
9 mm. [-f inch] in length. The eggs 
are, likewise, considerably smaller. 
Both are found in the gall bladder 
Egg of and bile ducts. The eggs are some- 

Distomum . 

haematobium, times found in the fseces. 
The Distomum hamatobium occurs in the tropics. 
It lives in the abdominal veins, and causes diarrhoea, 
haematuria, and chyluria. The male is 12-14 mm. [J- 
inch] and carries in a groove in it the female, which is 
16-19 mm. [-§-} inch] long. The eggs are 0.12 mm. [^ 
inch] long, are found in the urinary sediment, and have 
a point either at one pole or on the side (fig. 44). 

Arthropodes. 

Acarus (sarcoptes) scabiet, or itch-insect is an oval 
lenticular body with eight short legs. The female is 
found at the end of the furrow, which is filled with the 




PARASITES. IOI 

eggs and excreta of the insect. In 8 to 14 days the 
young ones are hatched, and in turn bore into the skin. 

Acarus (demodex) folliculorum is longer than it is 
broad, and is found in comedones, especially in the face. 

Pediadus capitis, or head louse ; Pediculus vestinmiti, 
or body louse ; Pediculus pubis, or crab louse. Pulex 
irritans, or flea. 

Protozoa. 

In the stools the following protozoa are sometimes found in 
chronic diarrhoea : 

Am<zba coli, a round granular structure with a nucleus and a few 
vacuoles. Cercomonas intestinalis, pear-shaped animalculae (8-10 ju 
{.TG~W5 i ncn ] l° n g). with ciliated extremities. Trichomonas intesti- 
nalis (10-15 M- [gV"r& i ncn ] l° n g)> almond-shaped with ciliated ex- 
tremities. Balantidium or Paramceciiim coli, pear-shaped, 70-100 
ju [|— |- inch] long, ciliated, with an inverted mouth. Besides these 
protozoa, there are found in the vaginal secretion, trichomonas vagi- 
nalis, and in other secretions other protozoa. 

Vegetable Parasites. 

Hyphomycetes or Moulds. 

Achorion Schoenleinii, ox f amis fungus, is in the shape 
of worm-like filaments, which are provided with septa 
and lateral elevations, and in their ends are round or 
oval, brightly shining spores (conidia). 

The Tryclwphyton tonsurans is the fungus of herpes 
tonsurans and circinatus, as well as of acne mentagra 
(sycosis parasitaria). The mycelium consists of curved 
and branching filaments provided with septa. The fila- 
ments have partly at their ends shining spores (conidia) 
with double contour. In the epidermis the fungus fila- 
ments are found, while in the hair and hair-sheath the 
spores (conidia) are found. 

The Microsporon furfur, or fungus of pityriasis ver- 



102 CLINICAL DIAGNOSIS. 

sicolor, is found in the yellowish epidermis scales in 
large numbers as a dense network of curved, more or 
less branched filaments, with heaps of shining spores 
(conidia) within. 

The Microsporon minutissimum is a very fine non- 
branching filamentous fungus without the formation of 
spores, and is found in erythrasma, but whether in 
causal relation or not is doubtful. 

The oidium albicans, or thrush fungus, is found in the 
mouth cavity as well as in the oesophagus and the stomach. 
It consists of branching filaments, with shining, round or 
oval spores (conidia) at the points of bifurcation. 

The Aspergillus glaucus and niger are often found in the 
sputum of consumptives or imbeciles, and may cause a 
peculiar kind of pneumonia called pneumonomycosis as- 
pergillina. They are filaments more or less branched, with 
double contour and with many brown pigmented spores. 

In order to make the filamentous fungus visible, the preparation 
(from a scraped tongue, epidermis scales, hair, etc.) is allowed to 
stand for a few minutes in a 10 % caustic potash solution, which 
makes the albuminous substances and epidermis more translucent, 
and the fungus thereby all the more distinct. 

Yeast fungi are frequently found in fermenting condi- 
tions of the stomach. 

Schizomycetes or Bacteria. ' 
Morphologically we distingnish 

(a) The Coccus (spherical or oval), and according as 
the cocci are single, in twos, in chains, or in a racemose 
conglomeration, they are called monococcus, diplococcus, 
streptococcus, and staphylococcus. 

(b) Bacillus or rod. 

(c) Vibrio, or curved rod, fragments and developing 
form of spirilla as comma bacilli. 

1 v. Appendix. 



PARASITES. 



I03 



(d) Leptothrix forms. Filiform. 

(e) Spirillum. Spiral form. 

To the Cocci belong also the micro-organisms of erysipelas (round 
streptococci) and of puerperal fever, of gonorrhoea (bean-shaped dip- 
lococci which are found in clumps, partly in the leucocytes of the 
gonorrhceal pus), of croupous pneumonia and the pus-producing 
cocci, staphylococcus pyogenes aureus, the coccus of acute osteo- 
myelitis, and staphylococcus pyogenes albus, etc. 

To the Bacilli belong the micro-organisms of tuberculosis, of lepra 
(syphilis), of anthrax, malleus (glanders), typhoid fever, diphtheria, 
malignant oedema. As comma bacilli, are to be mentioned the cholera 
bacillus and the bacillus of Finkler-Prior. 

To the Spirilla belong the Spirochseta Obermeieri, in recurrent 
fever, and the Spirochseta buccalis and others. 



Figs. 45-53. 



3l 

Fig. 45- 
Bacillus mallei. 



Fig. 49- 



» 




Fig. 46. 

Bacillus typhosus 

(Eberth). 



Fig. 47- 

Bacillus leprae 

(Hansen). 



4 \«p 



J 






'& 



•?:• 



Fig. 48. 

Bacillus tuberculosis 

(Koch). 



\ si" 



Fig. 50. Fig. 51. Fig. 52. Fig. 53. 

Bacillus anthracis. Spirillum of spirochasta Bacillus (s. spiril- Gonococcus Streptococcus 

Obermeieri lum) choleras Neisseri. erysipelatis. 

(relapsing fever). Asiatics (Koch). 

Clinically, the coloring of the micro-organisms in a 
dried preparation is almost exclusively used. 1 



1 The preparation and the staining of the sections, as well as the 
methods of bacteria culture, are subjects too extensive to be taken 
up here. They may be better studied in the " Proceedings of the 
Royal Board of Health" (Berlin); Cornil et Babes: " Les Bac- 
teries " ; Friedlaender : " Microscopical Technique " ; Hueppe : 
" The Methods of Bacterial Investigation." 



104 CLINICAL DIAGNOSIS. 

A small drop or particle of the substance (blood, pus, 
sputum, tissue juice, etc.) to be examined is spread with 
a platinum needle upon a clean cover-glass, or two glasses 
are rubbed together so that a thin film of the matter is 
deposited on each. The cover-glasses are then to be 
protected from the dust and left until dry. Then the 
glass, with the preparation side turned upward, is passed 
three times moderately quickly through the spirit flame. 
Dry preparations of blood should be heated a few hours 
at a temperature above ioo° C. (212 F.), in order to fix 
the hemoglobin, and the best way to accomplish this, 
according to Ehrlich, is to put the glass on a metal plate, 
to one corner of which the heat is applied. The dried 
preparation may then be colored. 

In clinical examinations aniline colors are principally 
used, and among them the following : 

(a) The acid aniline colors : Eosine, picric acid (prin- 
cipally in blood examination). 

(b) The basic aniline colors : Fuchsin (muriate of 
rosaniline), methyl blue, methyl violet, and gentian violet, 
vesuvin (Bismarck brown), and malachite green. 1 Of 
these colors it is well to have on hand either a concen- 
trated, watery filtered solution, or, what is better in the 
case of fuchsin, a concentrated alcoholic solution. 

The coloring of the dried preparations is carried out 
either by dropping with a glass rod some of the concen- 
trated watery solution on the preparation, or, if the 
object is to let the color work in for a longer time, by 
letting the cover-glass float, with the preparation down- 
ward, on the surface of the staining fluid in a watch-glass. 
In using methyl violet, gentian violet, or malachite green 

1 These colors may be obtained from W. Konig, Berlin, N. W. 
Dorotheenstrasse, 35. 



PARASITES. I05 

in a concentrated watery solution J-i minute is long 
enough to color ; in the case of fuchsin and methyl blue 
it is well to use more diluted solutions for several minutes 
until the proper tinge is obtained. This latter has the 
advantage over the other stains in not over-coloring, but 
in staining the nuclei and bacteria distinctly and causing 
no precipitate (Ehrlich). Vesuvin (Bismarck brown) 
should be used in a concentrated watery solution for 
several minutes. 

When the preparation is sufficiently colored it should 
be washed off carefully with water. Then the cover-glass 
is pressed between folds of .filter paper and finally dried 
by holding it over the flame, and then examined in 
Canada balsam (dissolved in turpentine) or in cedar oil. 

The fundamental principle in examining stained bac- 
teria preparation is to remove the diaphragm from the 
microscope stage, and, if possible, then use the Abbe 
illuminating apparatus [condenser] without the dia- 
phragm, making the contour of the preparation more 
indistinct, and thus causing the colored objects to be 
more prominent. But in all other microscopical exami- 
nations in which the endeavor is to have the clearest 
possible outline in an uncolored preparation — e. g, } in 
looking for hyaline casts, the narrowest diaphragm ad- 
missible should be used. 

Almost all micro-organisms except the tubercle bacil- 
lus may be colored in dry preparation according to the 
above methods. 

The staining of tubercle bacilli as done according to Ehr- 
lich. Aniline water is prepared by shaking up one or 
more ccm. of aniline oil with 20 ccm. [5 drachms] of dis- 
stilled water, and allowing it to stand a short time, and 
then filtering. To the clear filtrate, which may be heated 



106 CLINICAL DIAGNOSIS. 

to boiling in a test-tube to hasten the coloring, 5-10 
drops of a concentrated alcoholic solution of diamond 
fuchsin are added in a watch-glass until the fluid begins 
to opalesce. 

Instead of this solution, which should be prepared fresh every 
time, the following of Weigert-Koch may be used, which can be 
kept 10-12 days. Saturated aniline water 100 ccm. [3 ounces], a con- 
centrated alcoholic solution of fuchsin or methyl violet II ccm. [2| 
drachms], absolute alcohol 10 ccm. \l\ drachms]. 

The preparations, smeared on a cover-glass, are al- 
lowed to float on the solution 3-12 hours (if the solution 
be heated, 5—20 minutes are long enough), then taken 
out with the forceps, dipped for a few seconds into 
diluted nitric or hydrochloric acid (1:3 water), then at 
once thoroughly washed with water. If the preparations 
have a red color the procedure should be repeated until 
this color disappears. All bacteria are decolorized by the 
acid except the tubercle bacillus (and lepra bacillus). 
This preparation should then be colored by a drop of 
concentrated watery solution of malachite green or 
methyl blue, again washed thoroughly with water, dried, 
and examined in cedar oil or Canada balsam. The tu- 
bercle bacilli will then be found to be colored red, while 
every thing else present is green or blue. The tubercle 
bacilli may be recognized with a power of 350 diameters. 

The isolated method of staining micro-organisms accord- 
ing to Gram. The preparations are first colored for 1-3 
minutes in a solution of aniline water which has been 
saturated with gentian violet, and then put into a solu- 
tion of iodine in iodide of potash, 1 and then in absolute 

1 Iodine 1.0 [15 grains]. 
Iodide of potash 2.0 [30 grains]. 
Distilled water 300.0 [9J ounces]. 



PARASITES. I07 

alcohol until the preparations are decolorized. The prep- 
aration is then to be stained with vesuvin and examined 
in water, or dried and examined in cedar oil or Canada 
balsam. The micro-organisms are colored bluish black. 

In order to stain the pneumonococci of Friedlander, 
and their capsules, there may be made, either a solution 
of gentian violet in aniline water, or the solution which 
Ehrlich uses to stain the plasma cells. 1 The preparation 
should remain twenty-four hours in the solution, and 
then put in \<f acetic acid for a few minutes, then in 
alcohol, turpentine, and Canada balsam. The Lepra 
bacilli are colored just as well in gentian violet or methyl 
violet as, according to the procedure of coloring, the 
bacilli of tuberculosis. The micro-organisms of typhus, 
recurrent fever, glanders, anthrax, pyozmia, erysipelas, etc., 
may be shown with any of the basic aniline colors. 

To color the gonococci, a drop of gonorrhoeal pus is 
pressed between two cover-glasses, spread out to a thin 
film upon a slide, and to it are added a few drops of a 
concentrated watery solution of methyl blue, which is 
washed off in a half minute, and then dried and ex- 
amined in Canada balsam or cedar oil. 

The actinomycosis or radiating fungus, whose place 
among the micro-organisms is doubtful, is found in pus 
in the form of yellow-white granules of the size of a 
millet seed, which consist microscopically of a large 
number of fine radially arranged filaments, which end 
in thick, shining knobs. The masses of actinomycosis 
are often calcified, and should first be decalcified with 
diluted hydrochloric acid. Staining is superfluous. 3 

1 Concentrated alcoholic solution of gentian violet, 50.0 [1^ ounces]. 
Glacial acetic acid, 10. o \o.\ drachms]. 

Distilled water, 100. o [3 ounces]. 

2 v. Appendix. 



CHAPTER XII. 

THE NERVOUS SYSTEM. 

Testing the Sensibility. 

We distinguish Anesthesia, a loss or diminution of 
sensation. Hyperesthesia, an exaltation of the same, 
weak stimuli causing unpleasant sensations. Parcesthe- 
sice, or abnormal sensations which are not due to ex- 
ternal causes, as itching, crawling, formication, furry 
feeling, abnormal sensation of heat and cold. Neuralgia 
are attacks of pain which are confined to a certain nerve 
region, and they generally follow the course of the nerve. 
They are generally increased by pressure on the nerve on 
that part which is subcutaneous, and when it is pressed 
against a bone (pressure point). In genuine neuralgia 
the pain is in paroxysms. 

The sensibility may be equally diminished for all kinds 
of sensation or for some kinds only (total and partial 
anaesthesia). These kinds of sensations are : 

Touch sense, which may be tested by delicately touch- 
ing the part affected with the finger-tip or any other ob- 
ject. The patient, whose eyes are covered, should be 
very attentive to note the slightest touch. The test may 
be made between smooth and rough (woollen) objects. 
The temperature sense must then be excluded. 

The sense of locality. — The patient should be touched, 
108 



THE NERVOUS SYSTEM. 



IO9 



1 mm. [^ inch]. 

* " Ih " ]■ 



]• 



and then asked to show what part was touched. Healthy 
individuals rarely miss, or err by 1-2 cm. [|-| inch] only. 
Or, by using a pair of compasses, the smallest distance 
may be found in which the two points applied at the 
same time and in the same way can be recognized as 
two points. The distance in health for the following 
localities is as follows : 

Tip of the tongue 

Tip of the finger . 

Red surface of the lips 

Dorsal surface of the first and sec- 
ond phalanx and inner sur- 
face of the fingers 

Tip of the nose . 

Dorsal and palmar surfaces 

Chin . 

End of big toe, cheek, and eyelids 

Bridge of the nose 

Heel 

Back of the hand 

Neck . ... 

Forearm, leg, dorsum of the foot 

Back 

Upper arm and thigh 

Sense of pressure (muscular sense). — The extremity to 
be tested should be firmly supported and weights laid 
upon it, a small piece of board being put between 
the weight and the extremity to eliminate the sense of 
temperature. Under normal conditions a difference of 
•^y- of the original weight can be recognized, as well as a 
minimum pressure of 0.002 to 1.0 gram [^ to 15 grains]. 
Greater disturbances of the muscular sense can be recog- 
nized by pressure with the finger. 



6 

7 
8 

9 
12 

22 
3° 
35 



ft 
ft 
ft 
ft 
ft 
ft 
ft 

[! 
ft 



40 mm. [1 inch 
60-80 mm. [i|-2 inches 
80 mm. [2 " 



IIO CLINICAL DIAGNOSIS. 

Sense of te?nperature. — Test tubes, or metal vessels 
filled with water of different temperature, are applied to 
the skin. Between 25-35 C. [77-95° F.] a difference 
of |° in the temperature is recognized by a healthy per- 
son. The test may be made by letting the patient en- 
deavor to distinguish between warm breath near the skin 
and cold breath from a distance. Many patients will say 
that the irritation from the cold (ice) is hot, and vice 
versa (perverted temperature-sense). 

Electro-cutaneous sensibility. — By applying a metal 
brush to the skin, it may be ascertained with what 
strength of current (distance of the coils) the faradic 
stream has been felt. 

Sensibility to pain is tested by sticking with a needle, 
pinching, pulling the hair, and using strong electric cur- 
rent. If strong and painful irritation, as deep puncture 
with a needle, be felt as if the needle only touched the 
skin, without pain, then it is called analgesia. Analgesia 
occurs with unimpaired tactile sense in hysteria and 
tabes. Also the reverse -may be noticed, i. e., simple 
contact may cause pain. There is often a delay experi- 
enced in the transmission of the sensation of pain, or an 
abnormal after-sensation, and, at times, the tactile and 
pain-producing sensations are separated and are per- 
ceived one after the other (a double sensation). 

The sensitiveness of the deep parts — the muscles, fasciae, 
tendons, ligaments, joints, periosteum, and bones — is 
classed as follows : 

1. The ability to judge of the weight of a body when 
raised up, i. <?., the sense of force or muscle sense ; this 
is tested by lifting up a cloth to which weights are 
gradually added, and estimating the weight. The sense 
of force is finer than the sense of pressure. 



THE NERVOUS SYSTEM. Ill 

2. The ability to judge, with closed eyes, of the position 
of one's extremities and their passive movements ; or it 
may be tested by letting the patient close his eyes and 
attempt to touch one extremity with the other ; or, 
further, the power to hold the body in an upright position 
when the eyes are closed. If the patient stand firm with 
open eyes, and totter or fall when the eyes are closed 
(symptom of Romberg), then the sensibility of the limb 
is diminished. 

Testing the Motility. 

When the power of voluntary motion in a muscle is 
completely lost, we speak of paralysis , and when this is 
only weakened, of paresis. According to the extent of 
the paralysis, we speak of a monoplegia or paralysis of 
single muscles or group of muscles, or of an extremity 
by itself ; hemiplegia, paralysis of one side ; paraplegia, 
paralysis of corresponding parts of both sides of the 
body, i. e.y of both limbs, or of both arms, or of all four 
extremities. 

It should be noticed whether the state of muscular 
tension deviates from the normal or not. In diminished 
tension the paralyzed muscles are relaxed, and make no 
opposition to passive movements. This relaxed paralysis 
occurs principally in peripheral lesions in diseased con- 
ditions of the anterior gray horns or gray nuclei, as in 
infantile paralysis. 

In increased tension the muscles are stiff, rigid, and 
oppose all passive movements. If the tension is in- 
creased, it may lead to contraction. The rigid, so-called 
spastic paralysis presupposes a central lesion (of the 
brain or spinal cord), and occurs principally in degenera- 
tion of the lateral pyramidal tracts of the spinal cord, 



112 CLINICAL DIAGNOSIS. 

in spastic spinal paralysis, in amyotrophic lateral scle- 
rosis, in cerebral apoplexy or embolisms, etc. Spastic 
paralysis goes hand in hand with an exaggerated tendon 
reflex, while in relaxed paralysis there is a diminution or 
absence of the tendon reflex. 

In contradistinction to the orga?iic paralyses, in which 
the motor tract in any part is injured, we speak of a 
functional paralysis, where the motor tract is unimpaired, 
/. e., in hysterical paralysis. 

Ataxia means the inability, with intact power, to coor- 
dinate the separate muscles to a certain action — that is, 
a condition in which the patient makes clumsy motions, 
when he was previously skilful. He is asked to quickly 
reach for a certain object, to button a button, to write, 
to walk a straight line, to turn himself around, to describe 
a circle with the foot, etc. The patient shows ataxia 
when on the feet, by standing with the feet wide apart, 
and walking stiff-legged or stamping along. When the 
patient cannot control his movements with his eyes (in 
the dark, and with closed eyes), the ataxia is generally 
worse. Ataxia occurs in diseases of the spinal cord 
(tabes), as well as of the brain and peripheral nerves 
(cerebellar, alcoholic, diphtheritic ataxia). 

Motor Symptoms of Irritation. 

Spasms, or involuntary muscular movements, are 
divided into clonic (interrupted quiverings of short dura- 
tion), and tonic (contractions of longer duration). If the 
tonic spasms extend to most of the muscles, it is called 
tetanus. Convulsions are numerous quick, powerful 
clonic spasms, especially if they extend over the whole 
body. 

Tremors occur either in muscles at rest (in paralysis 



THE NERVOUS ST STEM. 113 

agitans), or in muscles voluntarily moved, especially in 
the movements which demand strength or precision 
(tremor of intention as in multiple sclerosis). Trembling 
of the eyes is called nystagmics (multiple sclerosis). 

Choreic movements are quick, involuntary, and incoordi- 
nate movements which interrupt and prevent the volun- 
tary motion. They occur in chorea minor, and at times, 
on one side after (or before) hemiplegia. 

Further, the following are to be mentioned : Compul- 
sory movements (riding motion), accompanying motions 
(generally central), athetosis motions (slow and rhythmic 
exaggerated movements of the hands), and cataleptic 
(waxy) muscular rigidity. 

Diagnosis by Means of Electricity. 

The test should be made both with the faradic (inter- 
rupted) and galvanic (constant) current, both by direct 
application to the muscles, or by indirect excitation of 
the muscles through the nerves. The indifferent \i. e., 
non-active] pole (a long, flat electrode) is placed on the 
sternum, and the other, different \i. e., active] pole, on 
the nerve or muscle to be examined. A small, button- 
shaped electrode serves for the different pole, since 
it must be taken into account, for the effect of the 
electrical excitation, that the current reach the part to 
be excited, with the greatest density. The density (D) is 
greater in proportion as the intensity (I) of the current is 
greater, and the section of the conductor (S) is smaller at 
the spot : D = §. 

The electrodes, as well as the skin of the patient, 
should be well moistened with warm water. The situa- 
tion of the points in which a muscle or nerve may be 



U4 



CLINICAL DIAGNOSIS. 



excited, is shown in the accompanying illustrations. 1 
By gradually increasing the strength of the current, we 
arrive at a point where the first minimum muscular con- 
traction takes place. 

The examination is begun with the faradic current 
and generally with the current of the secondary coil. 

Fig. 54- 



Region of central 
convolutions. 



Region of third 
frontal convolu- 
tion and island 
of Reil. 

M. temporalis. 

U. branch. 



r 

M. 



facial, j Trunk. 

'-L. branch. 

N. auricular post. 

M. splenius capitis. 



M sternocleido- 
mastoid. 



N. accessor Wil- 

lisii. 

M. cucullaris. 

N. dors, scapulae. 

N. axillaris. 

N. thoracic, long. 

(M. serratus anti- 



N. phrenicus. 
Plexus brachialis. 




M. corrug. super- 
cil. 

M. orbicular, pal- 
pebr. 

M. levator labii 
super, alaeque 
nasi. 

Mm. zygomatici. 

M. orbicular, oris. 

M. masseter. 

M. levator menti. 

M. quadrat, men- 
ti. 
M.triangul. menti. 

N. hypoglossus. 



Platysma 



myoides. 



luscles of hyoid 
bone. 



N. thoracicus an- 
terior (M. pecto- 
ral major.) 

Supraclavicular point of Erb (Mm. deltoideus, biceps, brachial, intern, [anticus], 
supinator longus et brevis, infraspinatus et subscapularis). 

As a standard of measurement of the intensity of the 
current, the distance between the coils (R. A.) is ex- 
pressed in millimetres, and the current is stronger in pro- 
portion as the coils are further apart. 

1 These are drawn from the illustrations in the text-books of Ziems- 
sen, Erb, Bernhardt, Rosenthal and Eichhorst. For details as to 
electro-diagnosis, as well as electro-therapeutics, see these books. 



THE NERVOUS SYSTEM. 115 

Also the faradic current must be graded by moving 
the iron rod (in the coil) ; for the current is so much the 
stronger in proportion as the rod is pushed further into 
the primary spiral. 

In using the galvanic current 1 the cathode 2 (negative 
zinc pole) is applied to the muscle or nerve to be examined. 
By gradually increasing the strength of the current, it 
may be determined what the least intensity is, with 
which, at the closing of the current, a contraction takes 
place (cathodal closing contraction, KaSZ 3 ). The in- 
tensity is noted by giving the number of elements used, 
or by reading off the number on the galvanometer. 

Then the current is used unclosed, with the commuta- 
tor, (from N, the normal position, to W, change), by 
which the exciting electrode becomes the anode (the 
positive, carbon, or copper pole), and determines the 
minimum of contraction on closing (anodal closing con- 
traction, AnSZ) and on opening (anodal opening con- 
traction, AnOZ). The closing and opening of the 



1 In filling the carbon zinc elements, the following fluid is used : 
Bichromate of potash, 70.0 [17^ drachms]. 
Water, 900.0 [28 ounces]. 

Concentrated sulphuric acid, 170.0 [5J ounces.] 
Sulphate of mercury, 10.0 \p\ drachms]. 
The last ingredient is to keep the zinc amalgamated. 
7 In order to distinguish the two poles, the ends of the wire 
should be immersed in a solution of iodide of potash and starch, and 
blue clouds, due to the free iodine and starch, are formed at the 
anode. Or the ends of the wires may be dipped in water, and the 
bubbles of hydrogen will show which is cathode, while the anode is 
recognized by the absence of bubbles, due to the rapid oxidation of 
the oxygen as fast as it is formed. 

3 [For the sake of uniformity, the German abbreviations are used 
throughout.] 



Il6 CLINICAL DIAGNOSIS. 

current should be effected by the interrupter without 
changing the position of the electrodes. 

Under normal conditions, the results of the irritation, 
on gradually increasing the intensity of the current, are 
in the following order : — 

(i) Cathodal closing contraction, KaSZ. 

(2) Anodal opening contraction, AnOZ. 

(3) Anodal closing contraction, AnSZ. 

(4) Cathodal closing tetanus, KaOZ (lasting contrac- 
tion with KaS). 

(5) Cathodal opening contraction, KaOZ. 

This law holds good, however, only in indirect irrita- 
tion of the nerves. In direct application of the electrode 
to the muscle, there are generally closing contractions, 
and AnSZ may be equal to KSZ or even greater than it. 

The contractions are short, quick, and may be excited 
through the nerve or muscle. 

The intensity of the current is expressed by the num- 
ber of elements used, or still better, when an absolute 
galvanometer is at hand, in milliamperes. 

According to Ohm's law I = ^ ; that is, the strength of 
the current or intensity (I) is in proportion to the electro- 
motive force (E, number of elements), and is in inverse 
proportion to the whole amount of the resistance pres- 
ent in the electric current. Now an ampere is that 
strength of current (I) which is generated by the electro- 
motive force (E) of 1 volt in an electric current of re- 
sistance (W), of 1 ohm. An ampere then, is equal to 
^^. One volt is equal to T 9 „- of the electromotive force 
of a Daniell element ; one ohm is equal to a column of 
mercury 106 cm. long, and 1 square millimetre in section 
(1.06 Siemen's unit). For medical purposes, no strength of 
current higher than 20 thousandth (milli-) amperes is 



THE NERVOUS SYSTEM. WJ 

used. With motor nerves superficially situated KaSZ 
occurs normally with currents of 1-3 MA strength. 

The strength of the current may be varied, either by 
inserting more or less elements, or by means of a rheo- 
stat, by which resistance of different degrees may be 
inserted into the current. 

The resistance in the dry epidermis is at first very great, but after 
using the galvanic current for some time, and thoroughly moistening 
the skin, the resistance is considerably diminished, so that by using 
a current of medium strength with the number of elements (E), re- 
maining the same, the strength of the current (I) increases to a 
certain point. A current which is not felt at the beginning of the 
examination, and causes no contraction, may, by keeping the current 
closed, and diminishing the resistance without changing the number 
of elements, so increase as to become painful and cause evident 
contraction. 

Quantitative changes in the electro-irritability, that is 
simple increase or diminution, are judged by comparing 
both sides of the body (in unilateral affections), and by 
testing analogous points which have approximately the 
same irritability in health, e. g., the frontal nerve, the 
spinal accessory in the neck, the ulnar nerve above the 
olecranon, and the peroneal nerve between the bend of 
the knee and the head of the fibula (Erb). Here it 
should not be forgotten that the conductive resistance of 
the skin is different in different parts of the body, and 
in different individuals. 

Simple increase of electric irritability occurs in tetanus, and a 
si??iple diminution of electric irritability may develop in all paralyses 
of long duration, which begin with simple non-degenerative muscu- 
lar atrophy, e. g., after apoplexy and muscular atrophy of the joint 
troubles. 

When there is a very great diminution of the electric irritability, 
a contraction may be caused, with the strongest currents, with 





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120 CLINICAL DIAGNOSIS, 

closed connection only, from the anode to the cathode (Volta's alter- 
native), and even this may be entirely extinguished. 

A qualitative change in the electric irritability, is called 
the reaction of degeneration (EaR). When a motor 
nerve is diseased or cut off peripherally from its trophic 
centre (the anterior horns of the spinal cord, or the gray 
matter of the cervical nerves), or if the trophic centre 
itself be diseased, a motor paralysis appears, the nerve 
becomes degenerated, and the degeneration (degenera- 
tive atrophy) reaches to the muscle supplied by it. The 
electric irritability of the nerve diminishes for the fara- 
dic, as well as for the galvanic current, and is destroyed 
after about two weeks, i. e., the nerve ceases to conduct 
the electric current as well as the will. Also the direct 
faradic irritability of the muscle is diminished and dis- 
appears ; on the contrary, in the 2d or 3d week there is 
an increase of the direct muscular irritability for the 
galvanic current, the contractions occur with the weak- 
est current, but are long drawn out and slow, and the 
formula of contraction is changed. The AnSZ occurs 
with the same or weaker current, as the KaSZ, and the 
KaOZ becomes like the AnOZ. In one or two months 
the galvano-muscular irritability diminishes, and disap- 
pears in a few months. If recovery take place the 
muscular tonus and voluntary motion appear, but the 
electric irritability returns only gradually to the normal. 

This " complete reaction of degeneration " only occurs 
in grave lesion of the nerves (transverse rupture, se- 
vere rheumatic facial paralysis); when the conditions of 
degeneration are not so grave, there is often an incom- 
plete, or even no " partial reaction of degeneration." In 
the latter case, the irritability for the nerves is retained, 
and also the direct faradic muscular irritability. In di- 



THE NERVOUS SYSTEM. 121 

rect galvanic irritation of the muscles, there are neverthe- 
less, hyperexcitability, and change of the formula of 
contraction (AnSZ > KSZ), and a slow contraction. 
The latter is the actual characteristic of EaR. 

The reaction of degeneration is present in peripheral lesions of the 
motor nerves, of a traumatic, rheumatic, neurotic, or diphtheritic 
nature, also in disease of the gray matter of the anterior horns of 
the spinal cord, and of the gray nuclei of the medulla, e.g., in in- 
fantile paralysis and lead paralysis ; also sometimes in progressive 
muscular atrophy, bulbar paralysis, amyotrophic lateral sclerosis, 
myelitis, etc. 

The EaR is absent, however, in all cerebral paralyses (apoplexies), 
and in those spinal paralyses which have a central cause from the 
trophic centre, and also in pure myopathic paralysis (pseudo-hyper- 
trophy of the muscles). 

The trophic behavior of the paralyzed muscles is en- 
tirely analogous to the electric behavior. In disease of 
the gray matter of the anterior horns, as well as in lesions 
of the motor nerves peripherally from themselves, a 
degenerative atrophy occurs, while in paralysis whose 
cause lies in the motor tract central from the gray mat- 
ter of the anterior horns, a slight atrophy of the para- 
lyzed muscle takes place, but not until after a long time 
(atrophy of inactivity). 

In degenerative atrophy of the muscles, there are often 
fibrillary contractions observed in them. 

Reflexes. 

We distinguish skin (superficial) and tendon (deep) 
reflexes. It is not certain whether the latter are actually 
reflex or not. They do not behave alike, and may be 
often completely different. 

Among the skin reflexes which are more or less 
present in health, are : 



122 CLINICAL DIAGNOSIS. 

Reflex of the sole of the foot : In exciting the sole of 
the foot by tickling, stroking, sticking, touching it with 
ice, there is dorsal flexion of the foot, and when the irri- 
tation is strong, the leg is drawn up against the body. 

Cremaster reflex : In exciting the inner surface of the 
thigh, the corresponding testicle rises- up. 

Reflex of the abdominal walls, gluteal and scapular re- 
gions : In irritating the skin in these regions, the corre- 
sponding muscles contract. 

Tendon Reflexes. 

Patellar reflex : If the patellar tendon be percussed 
while the leg is crossed and completely relaxed, and the 
patient's attention be withdrawn, there is a contraction of 
the quadriceps and the leg is extended. 

Patellar clonus : If the patella be pushed quickly down 
and held there firmly, there is a rhythmic contraction 
of the quadriceps. 

Reflex of the te?tdo Achillis ; In percussing the tendo 
Achillis, there is caused a contraction of the calf muscles. 

Foot clonus : If the foot be seized by the ball of the 
great toe, and be pressed quickly upward while the knee 
is slightly bent, there is a rhythmic plantar-contraction 
of the calf muscles. 

In health the patellar reflex is constant, and the reflex 
of the tendo Achillis frequent. The presence of the 
remaining tendon reflexes, also of the upper extremities 
(biceps, triceps, flexors of the hand etc.), is considered 
as a diseased reflex irritability. 

In order that the conditions of reflex tendon may occur, 
it is, above all things, necessary that the reflex circidt be 
entire. This reflex circuit is formed by the sensory 
nerve tracts, which go from the muscle or tendon or fas- 



THE NERVOUS SYSTEM. I 23 

cia, to the spinal cord and motor tracts which descend to 
the muscles, as well as to that part of the spinal cord 
connecting both. The reflexes are extinguished when the 
reflex circuit is interrupted in any part of its course, i. <?., 
when the centripedal or centrifugal nerves, or their con- 
nection with the spinal cord (Burdach's pyramidal gray 
substance), are injured. The reflexes are increased when 
these nerves are in an abnormally excited condition, or 
when the inhibitory fibres are interrupted in their course 
from the cerebrum through the lateral tracts to the reflex 
circuit. 

The tendon reflex is extinguished in polyomyelitis anterior (infan- 
tile paralysis), tabes dorsalis, peripheral nerve lesions, and diffuse 
myelitis. Increase of the tendon reflex is observed in sclerosis of 
the lateral tracts, in amyotrophic lateral sclerosis, in hemiplegia with 
contraction, in multiple sclerosis, division of the spinal cord above 
the reflex circuit, and further in dementia paralytica and hysteria. 

Paradox contraction (Westphal) : When the foot of the 
recumbent patient is quickly and firmly flexed, there is 
sometimes a contraction of the tibialis anticus, its ten- 
don is prominent, and the foot remains for a short time 
in this position after it has been let go. 

Among the reflex functions may be mentioned the 
passing of urine and faeces, the sexual reflex and pupil 
reflex. 

The pupil is supplied with fibres from the oculomo- 
torius for the sphincter pupillae as well as those from 
the sympathetic for the dilatator. A centre for the 
pupil reflex lies in the lower cervical region (cilio-spinal 
centre). Irritation of the sympathetic fibres coming from 
the centre, causes dilatation of the pupil (mydriasis spas- 
tica), paralysis of the same, a narrowing of the pupil 
(myosis paralytica). Irritation of the oculomotorius, on 



124 CLINICAL DIAGNOSIS. 

the contrary, causes narrowing of the pupil, and paraly- 
sis of it, dilatation, and want of reflex for light as well as 
for accommodation to near objects. Reflex rigidity of 
the pupil for light, with retained movement for accom- 
modation for near objects, occurs with narrowing and 
inequality of the pupils, most frequently in tabes dorsalis 
end dementia paralytica. 

The Most Important Clinical Points in the 
Anatomy of the Nervous System. 

Brain and Spinal Cord. — The psychomotor region of 
the cerebral cortex is formed by the two central convo- 
lutions and their connecting part on the median surface, 
the lobus paracentralis. The centre for the leg probably 
lies in the latter and in the two upper thirds of both the 
central convolutions ; and in the middle third of the an- 
terior convolution lies the centre for the arm ; and in the 
lower third of the anterior convolution, the centre for the 
face (facialis, hypoglossus). Bordering on the latter, and 
in the posterior portion of the third left lower frontal con- 
volution, as well as in the island of Reil, lies the centre for 
speech. When this is injured, aphasia occurs. The cortex 
of the parietal lobes is brought into relation with the sensi- 
ble tract ; the occipital lobe is the cortical centre for the 
sense of sight. As there is only a partial crossing of the 
fibres in the chiasma of the optic nerve, an injury to the 
occipital lobe or to the optic tract as far as the chiasma 
may cause hemianopsia, /. e. y blinding on the correspond- 
ing side of the retina ; thus a diseased condition of the 
right side causes a blindness in the left half of the field 
of vision. A diseased condition of the central part of 
the chiasma causes a bitemporal hemianopsia. In an 
injury to the optic nerve beyond the chiasma, there 



THE NERVOUS SYSTEM. 1 25 

occurs amblyopia, or amaurosis of one entire eye. The 
temporal lobes are connected with the sense of hearing. 
The functions of the corpus striatum, nucleus lenti- 
formus, and thalamus opticus are not exactly known, but 
as they border on the inner capsules, diseased conditions 
of them may indirectly cause hemiplegia. The cerebel- 
lum is said to be the centre for coordination. When it is 
diseased, we have ataxia, dizziness, and vomiting. 

The motor fibres of the psychomotor cortical portion 
pass through the peduncle of the corpus callosum, and 
converge to the inner capsule, where they run in the 
middle third of the posterior crus between the opticus 
thalamus and the nucleus lentiformis. In its posterior 
third the sensory tracts Flg - 59# 

Anterior pyramidal tract. 

are found. From the A ^ r t ior >W \JL 

/ito^mi&\^ Antero-lateral 

inner capsule the motor f JMfJfk "\ tract ' 

... [ ^ ® / \ Lateral pyramidal 

tracts pass through the ^fg| ^^ tract. 

. , , Cerebellar lateral 

pes cruris cerebri (the ^WJm \\ -__ 

. , .. Posterio r / ^-^K"^ Tract of Burdach. 

sensory through the teg- root - * \ „ 

3 O & Tract of Goll. 

mentum cruris cerebri) 

into the pons. The motor fibres, after their exit from the 
pons into the medulla, form the pyramidal bodies, and 
here, for the most part, cross. The crossed fibres in the 
lateral tract of the spinal cord pass downwards (lateral 
pyramidal tract, Fig. 59) ; only a small part of the motor 
fibres remains uncrossed, and passes down in the middle 
part of the anterior tract (anterior pyramidal tract). A 
destruction of any part of this motor tract produces, not 
only a paralysis of the muscle concerned, but also de- 
scending degeneration of the pyramidal tracts, inasmuch 
as their trophic centre is situated in the cerebrum. 
The motor fibres pass out of the pyramidal tracts into the 
anterior cornu of the gray matter, whose great ganglion 



126 CLINICAL DIAGNOSIS. 

cells form the trophic centre for the peripheral motor 
nerves and the muscles ; and from there they pass through 
the anterior roots to the periphery of the body. 

Injuries of the motor nerves beyond the gray anterior 
cornua, or a morbid condition of them, produce a degen- 
eration of the nerves, as well as paralysis and atrophy of 
the muscles, with the reaction of degeneration. These 
paralyses are characterized as peripheral, in distinction 
from central paralyses, which are caused by a lesion of the 
motor tracts proximal to the gray anterior cornua. 

Inasmuch as in the cerebral cortex the motor centres 
of the single muscular regions lie far apart from each 
other, a lesion in that particular place generally produces 
monoplegia, i. e., a paralysis of one member or of one 
group of muscles alone, which is often connected with 
paroxysmal cramps in the paralyzed portion (cortical 
epilepsy, Jackson's epilepsy). Lesion of the inner cap- 
sule generally produces total hemiplegia, as well as affec- 
tions of the crus cerebri and the pons. (In case of dis- 
eased condition of the crus cerebri, there is often with it 
a crossed paralysis of the oculomotorius ; when the pons 
is diseased, there is crossed paralysis of the facialis.) All 
these paralyses affect the opposite side of the body, while 
affections of the spinal cord before the pyramidal decus- 
sation cause paralyses of the same side. As most lesions, 
however, affect the spinal cord on both sides alike, para- 
plegia is the principal form of spinal paralysis (myelitis, 
compression of the spinal cord by spondylitis or tumors). 
Injuries of the anterior roots, of the plexus, and of the 
nerves, produce paralyses of single groups of muscles. 

The sensory nerves, whose trophic centre is situated in 
the intervertebral ganglia, enter the spinal cord through 
the posterior roots, cross shortly after their entrance 



THE NERVOUS SYSTEM. \2*J 

(deep decussation), and ascend through the posterior 
columns to the brain, so that the inner columns (of Goll) 
contain the long, ascending bundles of fibres, while the 
outer columns (of Burdach) are made up of short bundles 
which run to the gray posterior cornua. Besides that, 
long bundles in the lateral column of the cerebellum 
pass upward. 

In cases of transverse section of the spinal cord, the 
columns of Goll and cerebellar lateral columns degenerate 
upward from the point of injury, and the pyramidal column 
downward. In case of a lesion of one side of the spinal 
cord, there appears a motor paralysis of the same side, and 
anaesthesia of the other side ; besides this, a narrow anaes- 
thetic belt around the body at the height of the lesion 
(Brown-Sequard). In case of tabes dorsalis the posterior 
columns are diseased, and in spastic paralyses the lateral 
columns (tabes spastica). In amyotrophic lateral scle- 
rosis the anterior cornua and lateral columns are dis- 
eased, and in infantile paralysis and progressive muscular 
atrophy the gray anterior cornua are diseased. In dis- 
eases of the gray nuclei of the medulla oblongata (bulbar 
paralysis) there are disturbances of speech and degluti- 
tion caused by paralysis and atrophy of the lips, soft 
palate, muscles of deglutition, and larynx. 

Cranial Nerves. 

1. Olfactorius. The testing of the sense of smell is accomplished 
by holding before the nose odoriferous and irritating substances, such 
as volatile oils, asafoetida, musk, etc. 

2. Opticus. Test the sharpness and field of vision, and sense cf 
color, and then examine with the ophthalmoscope. 

3. Oculomotorius supplies the levator palpebrae superioris, rectus 
superior, internus, and inferior, obliquus inferior, and sphinctor pu- 
pillse. In paralysis, there is ptosis, diplopia, dilatation, and absence 
of pupillary reaction, and disturbance of accommodation. 



128 CLINICAL DIAGNOSIS. 

4. Trochlearis supplies the obliquus superior. 

5. Trigeminus. The motor part supplies the muscles of mastica- 
tion, the masseter, temporalis, pterygoid, mylohyoid, and the ante- 
rior belly of the biventer. The sensory part supplies the skin of the 
face and head as far as the ears. The first branch goes to the skin 
of the forehead, of the top of the head, of the upper eyelids, and of 
the bridge of the nose. The second branch supplies the upper half 
of the cheek and upper lip, and the third branch, the lower half of 
the cheek, the skin in the temporal region, and the chin. Besides 
this, the trigeminus supplies the cornea and conjunctiva and the mu- 
cous membrane of the mouth and nose, and the dura mater with sen- 
sory fibres. The lingualis from the trigeminus is the nerve of taste 
for the anterior two thirds of the tongue. 

6. The abducens supplies the abducens muscle. When it is para- 
lyzed, the eyeball cannot be turned outward. 

7. The facialis supplies all the mimic muscles of the face, and the 
stylohyoideus, and the posterior part of the biventer. From the re- 
lation of the facialis to the petrosus superficialis major nerve, and to 
the chorda tympani, it is clear that in a lesion of this nerve, proximal 
to the ganglion geniculi, the soft palate on the same side is paralyzed 
and hangs lower, and that in a lesion between the ganglion geniculi 
and the passage of the chorda tympani, disturbances of taste occur in 
the anterior two thirds of the tongue, with decrease of the salivary 
secretion. In central paralysis of the facialis, only the lower half 
of the face is usually paralyzed ; in peripheral paralysis, only the 
upper part. 

8. Actisticus. The power of hearing should be tested, and oto- 
scopic examination made. 

9. Glossopharyngeus. The nerve of taste for the posterior third of 
the tongue supplies the palate with sensory fibres. The test is to 
apply quinine, sugar, salt, or vinegar to the part. 

10. The vagus supplies the larynx, pharynx, and oesophagus with 
motor and sensory fibres, and sends fibres to the contents of the chest 
and abdomen. Irritation of the vagus causes slowing of the pulse ; 
and paralysis of the nerve, a quickening of the pulse and slowing of 
the respiration. 

11. The accessorius supplies the sterno-cleido-mastoid and the 
trapezius. 

12. The hypoglossus, the motor nerve of the tongue, supplies the 



THE NERVOUS SYSTEM. I2Q 

genio-glossus, hyo-glossus, stylo-glossus, the innermost muscles of the 
tongue, the genio-hyoidcus, omo-hyoidcus, sterno-hyoideus, hyo- 
thyroideus, and sterno-thyroidcus. In paralysis of the hypoglossus, 
the tongue turns toward the paralyzed side. 

Spinal Nerves. 

1. Plexus cervicalis (ist-4th cervical nerve) supplies the post-occi- 
pital region behind the ear, neck, and shoulders with sensory nerves ; 
the deep cervical muscles and the scaleni, with motor nerves. From 
the fourth cervical nerve the phrenic branches, and forms the 
motor nerve of the diaphragm. 

2. Plexus brachialis (5th-8th cervical nerve, ist and 2d dorsal 
nerve). In lesion of a certain part of this plexus, there is a motor 
paralysis of the deltoid, biceps, brachialis internus [anticus], supin- 
ator longus, infraspinatus (paralysis of Erb). 

The nervi ihoracici anterioj'es supply the musculus pectoralis major 
and minor. 

The iiervus thoracicus longus supplies the musculus serratus anticus 
major [serratus magnus]. 

The iiervus dorsalls scapuhc supplies the musculi rhomboidei, levator 
[anguli] scapulas, and serratus posticus superior. 

The nervus suprascapularis supplies the musculus supraspinatus 
and infraspinatus. 

The nervus subscapulars supplies the musculus subscapularis, teres 
major, and latissimus dorsi. 

The nervus axillaris supplies the musculus deltoideu-, teres minor, 
and sensory fibres go to the skin of the outer side of the upper arm. 

The nervus cutancus medius and medialis supply the skin of the 
median (inner surface) side of the forearm. 

The nervus musculocutaneus supplies the musculus biceps, coraco- 
brachialis, brachialis internus [anticus], and the skin on the radial 
side of the forearm. 

The nervus medianus supplies the musculus flexor carpi radiahs, 
pronator [radii] teres and pronator quadratus, flexor digitorum com- 
munis superhcialis and profundus (in part), palmaris longus, flexor pol- 
licis longus and brevis, abductor and opponens pollicis ; the skin of 
the palmar surface of the hand from the thumb to the middle of the 
third [ring] finger ; and the dorsal side of the ungual phalanx of the 
first and second finger. 



I30 CLINICAL DIAGNOSIS. 

In paralysis of this nerve, pronation and flexion of the hand is al- 
most entirely impossible, and flexion and opposition of the thumb 
and flexion of the finger in the last two phalanges, is impossible ; on 
the contrary, the first phalanges can be flexed by the interossei. 
With the last three fingers, whose flexor profundus is partly supplied 
by the nervus ulnaris, the power of grasping is still retained. 

The nervus ulnaris supplies the museums flexor carpi ulnaris, flexor 
digitorum profundus for the last three fingers, the muscles of the ul- 
nar side of the hand, the interossei, lumbricales, adductor pollicis ; 
the skin of the ulnar side of the hand on the palmar side as far as the 
middle of the third [ring] finger, and on the dorsal side to the middle 
of the second finger. 

In paralysis of this nerve there is diminished power of lateral move- 
ment towards the ulnar side as well as loss of power to flex the last 
three fingers : further, also, there is loss of motion of the little fin- 
ger in flexion of the first phalanges and extension of the last pha- 
langes of the four last fingers, and loss of power to spread the fingers 
out and draw them together. In paralyses which have existed a long 
time we have the claw-like position of the hand, in which case the 
first phalanges are flexed towards the dorsal surface and the end 
phalanges towards the palmar surface. This is caused by atrophy of 
the interossei. 

The nervus radialis supplies the extensors of the arm,, hand, and 
fingers, the musculus triceps, supinator longus and brevis, all the 
muscles on the posterior surface of the forearm, namely, the extensor 
carpi radialis longus and brevis, extensor carpi ulnaris, extensor digi- 
torum communis, extensor indicis and digiti minimi, extensor pol- 
licis longus and brevis, abductor pollicis longus. The cutaneous 
branches go to the posterior surface of the upper arm and forearm, to 
the dorsal surface of the thumb, and the skin as far as the middle of 
the second finger. 

In paralysis of this nerve there is inability to extend the relaxed 
muscles of the hand and fingers, as well as to extend and abduct the 
thumb. The outstretched arm cannot be supinated (but on flexion of 
the arm the forearm can be supinated by the biceps). Such a paraly- 
sis is observed in lead paralysis, except that the supinator longus is 
generally exempt. The sensory disturbances in paralysis of the 
nerves of the arm may be inferred from the above description of the 
distribution of the sensory branches, but the symptoms are generally 
less distinctly marked. 



THE NERVOUS SYSTEM. 131 

3. The dorsal nerves supply the skin and muscles of the thorax and 
abdomen. 

4. The plexus lumbalis (12th cervical to ist-4th dorsal nerve) goes 
to the skin of the lower abdominal region, of the anterior surface of the 
thigh, and of the inner surface of the leg. The motor branches sup- 
ply the internal pelvic muscles. The nervus cruralis supplies the 
musculus quadriceps femoris, sartorius, pectineus ; the nervus obtur- 
atorius supplies the musculus obturator, adductor magnus, longus, 
and brevis, and gracilis. 

5. The plexus sacralis (5th lumbar to ist-5th sacral nerve) supplies 
the bladder, rectum, sexual organs, perineum, and nates with motor 
and sensory branches. 

The nervus ischiadicus [sciatic nerve], which supplies the skin on 
the posterior surface of the thigh, on the outer side of the leg, and on 
the foot as well as the musculus biceps, semitendinosus and semi- 
membranosus, divides half way down the thigh into the nervus tibialis 
and peroneus, the former of which supplies the muscles on the pos- 
terior surface of the leg (calf muscles) and of the under surface of the 
foot, the latter going to the muscles on the anterior surface of the leg 
and foot (see Figs. 58 and 59). 



CHAPTER XIII. 

ANALYSIS OF THE PATHOLOGICAL CON- 
CREMENTS. 

Urinary Concrements. — The concrement should 
be rubbed to a fine powder, and a part of it heated red 
hot on a platinum spatula or on a porcelain crucible 
top. If the concrement be completely destroyed, or if 
only a small amount of ash remain behind, then it con- 
sists of organic substance, /. e., uric acid, urate of am- 
monia, xanthin, or cystin. 

Uric Acid is tested for with the murexide test, by moist- 
ening some of the powder on a crucible lid with a drop 
of nitric acid and slowly evaporating it. If uric acid is 
present an orange-red mark is left, which turns purple on 
being moistened with ammonia. Uric acid calculi are 
generally reddish-yellow and hard. 

Ammonia is tested for by dissolving the powder with 
dilute hydrochloric acid, filtering and making the filtrate 
alkaline with caustic potash, and heating it in a test tube. 
A smell of ammonia is developed, and moist red litmus 
paper, held over the opening of the tube, turns blue from 
the vapor ; and a glass rod moistened with muriatic acid 
and held over the opening of the tube causes a vapor of 
chloride of ammonia. If uric acid and ammonia are de- 
tected the calculus contains urate of ammonia. Such 
stones are generally white and crumbly. 

If the murexide test does not succeed, the xanthin is 
132 



PATHOLOGICAL CONCREMENTS. 133 

tested for by dissolving the powder in dilute nitric acid, 
and evaporating it slowly on a porcelain crucible top. 
If a lemon-colored residue is left which is unchanged on 
moistening it with ammonia, but turns red on adding 
caustic potash, then what remains is xanthin. Xanthin 
calculi are generally of a cinnamon-brown color, moder- 
ately hard, and take on a waxy lustre on being rubbed. 

Cystin is detected by dissolving the sediment with 
heat and ammonia. After evaporating, the filtrate may 
be recognized microscopically as regular hexagonal 
crystals of cystin. Cystin calculi are generally smooth, 
yellow, and not very hard. 

If the concrement is not completely consumed, but 
made black only, then it consists of inorganic substances, 
or of compounds of organic acids (uric or oxalic acid), 
with alkalies or alkaline earths. 

A little of the sediment is put into a test tube, and 
dilute hydrochloric acid is added. If effervescence take 
place, it is proof of the presence of carbonic acid. If 
the substance be not completely dissolved on heating, 
then the residue may consist of uric acid (to be detected 
by the murexide test). It should then be filtered, the fil- 
trate made alkaline with ammonia, and then made 
slightly acid with acetic acid. If then a white powdery 
precipitate, insoluble with heat, be left, it consists of the 
oxalate of lime. It should then be filtered, and oxalate of 
ammonia added. A white precipitate shows the pres- 
ence of calcium monoxide. This is heated and filtered, 
and ammonia added, and if a precipitate (ammonio- 
phosphate of magnesia) be formed after standing, it 
shows the presence of magnesia and phosphoric acid. If 
no precipitate be formed, the fluid is divided into two 
parts, and to one part phosphate of sodium and to the 



134 CLINICAL DIAGNOSIS. 

other sulphate of magnesium is added. The appearance 
of a precipitate in the first shows the presence oimagnesia; 
in the second, of phosphoric acid. Phosphoric acid may 
be detected in the fluid by adding acetate of uran after 
the acetic acid, and a yellow-white precipitate shows the 
presence of the phosphate of uran. 

Sulphuric acid may be detected by adding chloride of 
barium after the muriatic acid, and a white precipitate of 
the sulphide of barium results if sulphuric acid be 
present. 

Calculi of the oxalate of lime are generally very hard, 
of a mulberry shape, and are colored dark with the col- 
oring matter of the blood. They are not dissolved by 
acetic acid ; but are dissolved without effervescence by 
the mineral acids. 

Calculi of the phosphate of lime and of ammonio- 
phosphate of magnesia are generally white, soft, and 
friable. 

Calculi of the carbonate of lime are white, chalky, and 
effervesce on adding acids. 

The concrements of the intestine (faecal calculi) 
consist partly of organic substances of different kinds, 
and partly of inorganic salts, such as the phosphate of 
calcium, the ammonio-phosphate of magnesia, the sul- 
phates of the mineral alkalies. They should be dissolved 
in muriatic acid, and examined in the customary manner. 

Salivary calculi generally consist of carbonate of 
lime. 

Gall stones consist principally of cholesterine and 
bilirubin, in combination with calcium. To detect 
cholesterine the powdered concrement should be dis- 
solved in hot alcohol, and filtered, and after cooling the 
cholesterine crystallizes out of the filtrate in slender 



PATHOLOGICAL CONCREMENTS. 135 

plates. If the cholesterine be then dissolved in chloro- 
form and concentrated sulphuric acid be added, a beau- 
tiful cherry-red color is formed, which changes later to 
blue and green. To test for bilirubin the residue of the 
concrement is made slightly acid with muriatic acid and 
extracted with chloroform in a warm place. On adding 
fuming nitric acid to the chloroform the Gmelin reaction 
appears. 



CHAPTER XIV. 
METABOLISM AND NUTRITION. 

In order that the human organism shall retain its 
proper amount of albumen, fat, ashy residue, and water, 
there must be a sufficient amount and proper proportion 
of these substances in the daily food. Since the water 
and ashy residue are generally abundant, the principal 
question is of giving those nutritious substances which 
prevent the body from losing albumen and fat. These 
substances are the albuminous and fatty matters and the 
carbo-hydrates. 

In order to see whether an organism keeps up the 
proper amount of nourishment or not, it is not sufficient 
to consider the weight alone ; for the weight can remain 
the same, or even increase, while the nourishment de- 
creases, as in cases of hydrsemia, even without visible 
oedema. 

Albwiien is also set free 1 from the organism in hunger. 
In order that the body shall not lose its proper amount 
of albumen, a certain quantity should always be given 
with the food, which can be substituted by no other food. 
The smallest amount of albumen with which the body 
can be kept up to its standard is called the diet of sus- 
tenance. This for a medium-sized adult is about 85 grams 

1 In long-continued complete inanition, about 4.26 grams [63 
grains] of nitrogen, equivalent to 210 grams [6| ounces] of muscle, 
are split up and set free daily. 

136 



METABOLISM AND NUTRITION. 1 37 

[2 J ounces] (Voit '). If more albumen be given more is 
decomposed, and the body soon sets it free and quickly 
regains its nitrogenous equilibrium, /. <?., just as much is 
excreted as is taken up. The body possesses extensive 
powers of adaptation and can reach the nitrogenous equi- 
librium with the most different amounts of albumen, in 
case it does not fall below the diet of sustenance. Be- 
sides the amount of albumen necessary for the diet, the 
amount of albuminous decomposition is also dependent 
upon the body's richness in albumen, and therefore a 
muscular working man needs larger amounts of nutritive 
albumen, than a reduced sick man. The work itself has 
therefore no influence upon the amount of albumen con- 
verted ; for the workman sets free just as much albumen 
when resting as when working. If less albumen be given 
with the food than is necessary to keep the normal 
amount in the body, the organism loses its albumen 
and becomes poorer ia albumen. An increase of albu- 
men in the body cannot be brought about by admin- 
istering albuminous food only, but in addition there 
should be large quantities of fat and the carbo-hydrates 
in the diet, which prevent the albumen from splitting up 
and thus economize, as it were, the albumen. In fever 
more albumen is decomposed than normally, and the body 
may therefore lose an enormous amount of albumen, 
when very little is taken in with the food. 

Since the nitrogen which arises from the split-up albu- 
men is almost exclusively excreted through the urine 
(generally as urea, cf. p. 70), the amount of albumen con- 
verted in the organism may be calculated from the amount 
of nitrogen in the urine. One gram [ 1 5 grains] of nitro- 

1 Other authors give lower figures : 56 grams [if ounces], Meinert : 
57 grams [if ounces], Playfair. 



I38 CLINICAL DIAGNOSIS. 

gen in the urine is equivalent to a change of 6.25 grams 
[93 grains] of albumen, or of 29.4 grams [449 grains] of 
muscle (1 gram [15 grains] of urea is equivalent to 2.9 
grams [43 grains] of albumen and 13.72 grams [205 
grains] of muscle). If the amount of albumen in the 
food be known and also the amount passed with the fae- 
ces, by comparing these figures with the nitrogen excreted 
in the urine, it may be decided whether the organism has 
the proper amount of nitrogen, or whether it has gained 
or lost albumen. If, for example, a patient with typhoid 
fever take in twenty-four hours 5.977 grams [90 grains] 
of nitrogen, of which 1.087 grams [16 grains] of nitrogen 
are passed out with the faeces and 19.488 grams [292 
grains] with the urine, the body loses in this time 14.598 
grams [218 grains] more than it has assimilated, /. <?., it has 
lost 91.236 grams [1368. grains] of albumen (14.598 X 6.25 
grams [218 X 93 grains]) or 429.2 grams [6478. grains] 
of muscle (14.598 X 29.4 grams [218 X 441 grains]). 

A comparison of the amount of urea in disease with 
that in healthy individuals who are under entirely differ- 
ent conditions of nourishment, is not possible according 
to the above. 

In diseases of the urine-producing organs, as in nephri- 
tis, all the products formed in the body from the splitting 
up of albumen are not always excreted by the kidney, but 
they may be retained in the body. The danger of poi- 
soning with these matters (ursemia) is greater, as is easily 
understood, the more albumen taken in as food, and con- 
sequently with it the formation of products of albumi- 
nous decomposition. 

The change of the non-nitrogenous substances, i. e., of 
the fats and carbo-hydrates, is, as opposed to that of the 
albuminous formations, dependent upon the amount of 



METABOLISM AND NUTRITION. 1 39 

work and the production of heat. For example, a laborer, 
when working, sets free twice as much as when he is rest- 
ing. In fever when there is an increased production of 
heat, there is also an increased metabolism of the non- 
nitrogenous substances. The products of the metabolism 
of these substances are oxidized to water and carbonic 
acid and leave the body through the lungs. If less non- 
nitrogenous food is taken in than the body needs for 
work and the production of heat, then a part of the fat of 
the body is used. And if more fat or carbo-hydrates be 
taken up than are used, then fat is deposited. The fats 
and carbo-hydrates are the principal non-nitrogenous 
substances which are taken in as food, and they may take 
each other's place as food, just in proportion to the amount 
of heat (calories) which they contribute to combustion. 
When a certain quantity of albuminous substances (suste- 
nance) is given, never mind what substances they are; ioo 
grams [1500. grains] of fat have the same value (isodyna- 
mic) as 211 grams [3155. grains] of albumen, or 232 
grams [3480. grains] of starch, or 234 grams [3510 grains] 
of cane sugar, or 256 grams [3840 grains] of grape sugar 
(Rubner). 

If the object be to increase the amount of fat in an 
individual, then a smaller amount of albuminous sub- 
stances, with a very abundant non-nitrogenous diet should 
be given, and since fat cannot easily be taken in larger 
amounts than of 100 grams [1500. grains], the carbo- 
hydrates should be used. On the contrary, if the wish 
be to decrease the amount of fat in a body, then the 
smallest possible quantities of fat and carbo-hydrates 
with plenty of albuminous food should be given, and 
care should be taken that the fat be burned up by suffi- 
cient exercise (work). In diabetes the organism has 



140 



CLINICAL DIAGNOSIS. 



lost in a varying degree the ability to split up and use 
the carbo-hydrates. They are excreted in the urine 
unused as grape sugar. On the contrary, the body splits 
up large quantities of albumen and fat, and the loss of the 
carbo-hydrates therefore must be made up by a diet very 
rich in albumen and fat, but poor in the carbo-hydrates. 

The need of these substances is, therefore, very differ- 
ent for different persons. According to C. v. Voit the 
amount of food necessary for 





Albumen 


Fat 


Carbo- 
hydrates 
(grams). 


N. 


C. 




(grams). 


(grams). 


(grams). 


(grams). 


A muscular work- 


118 


56 


500 


J 9 


328 


man (of 70 kilo ] 


[3| oz.] 


[If OZ.] 


[15} oz.] 


[i oz.] 


[10 oz.] 


[140 lbs.] ) 












A moderately strong 


127 


80 


362 






man (physician) 


[4 oz.] 


[>f oz.] 


[11 oz.] 






An idle man (priso- 


87 


22 


305 






ner) 


[2| OZ.] 


[f oz.j 


[9 oz.] 







The need of food for growing individuals (children) 
is less than for adults, but greater in proportion to the 
weight of the body. 

The composition of the most important kinds of food 
is given in the table opposite. 

The nutritive substances are not completely absorbed 
in the intestinal canal, but a part of them is always 
passed out unused with the faeces. Under normal con- 
ditions animal albumen (meat, eggs, cheese, etc.) is very 
thoroughly used up, while vegetable albumen (bread, 
legumes, vegetables) are less thoroughly absorbed. The 

1 According to Pfltiger and Bohland the amount of albumen con- 
verted is in adults (of 62 kilo [T24 lbs.] ) equivalent to 96.467 grams 
[1447- grains]. 



metabolism and nutrition. 
Composition of Foods. 



141 





^ 


x^ 






\r 






be 

M CO 


53 




•fcs. 


O <D 




Food 


< 


N.* 




-fits 




Raw beef, lean, freed from all 














visible fat ... 


24.1 


18.36 


3-4 


0.9 




J 


Raw beef, moderately fat 




27.75 


2O.9I 




5.19 


0.48 


■i 


Raw beef, fat . 


. 


44-58 


17.19 




26.38 




'2 


Boiled beef 


. 


24.2 


21.8 




0.9 




3 


Roast beef 


. 


41-43 




4.89 


6.78 




4 


Raw veal . 


. 


27.69 


18.88 




7-41 


0.07 


•2 


Roast veal 




21.0 


15-3 




5-2 




^ 


Raw chicken (lean) 




23.78 


19.72 




1.4 


1.27 


i 


Hens' eggs (after taking off the 














shell) 


26.1 


14. 1 


2.19 


IO.9 




1 


1 egg weighs, without the shell, 














on an average, 45 grams [i| 














ounce]. 














Cow's milk (good quality) . 


12.92 


4-13 


0.64 


3.90 


4.20 


1 


Cow's milk (inferior quality) 


11. 7 


3-5 


0.5 


2-7 


4.5 


5 


Butter 


88.3 


0.5 




87.O 


0.5 


-1 


Cheese ..... 


66.8 


32.2 


4-75 


26.6 


2-97' 2 


i 


Bacon ..... 








95-6 




b 


Wheat flour (fine) 


85-M 


8.91 


1.42 4 


1. 11 


74.28 


'-' 


"White bread . 


72.0 


9.6 


i-5 5 


1.0 


60.0 


3 


Black bread .... 


63.29 


8.5 


1.0 




52.5 


1 


Pastry food (the average of seven 














varieties) .... 


44.2 


8.7 




15.0 


28.9 


3 


Raw potatoes (without skin) 


26.62 


2.31 


o.37 




23.3 


4 


Cooked potatoes (without skin) . 


25-4 


2.18 0.35 




23.0 


4 


Uncooked peas .... 


86.59 


21.25 3-40 


1. 17 


61.8 


4 


R.ice ...... 


86.5 


8.31 1-33 




89.2 


4 


Vegetables (average) . 


27-7 


2.2 0.35 


3-9 


18. 1 


■i 


Bouillon . 


0.09 


\o.osr 


0.8 




3 


Soup (the average of ten varieties) 


8-4 


1.1 




1-5 


5-7 


3 


White wine .... 


14.0 




0.033 




2.0 




Red wine (French) 


11. 7 




0.0182 5 




2-34 




Sherry . 


20.5 


0.20 






3.27 


2 


Bavarian beer . . . . 


9-7 


0.44 






5.78 





1 Analysis of C. v. Voit ; 2 of Konig ; 3 of Renk 
5 of F. Midler ; 6 of Hoffmann. 



4 of Rubner 



142 



CLINICAL DIAGNOSIS. 



carbo-hydrates (starch, sugar) are generally very com- 
pletely used up, while a very large part of the fats is 
passed out unused with the faeces. In many pathological 
conditions the absorption of the nutritious substances is 
badly carried out, as in diarrhoea. In absence of bile in 
the intestine (icterus), the fats are not easily absorbed. 

The absorption in health of some of the most im- 
portant articles of food is shown in the following table 
(Rubner) : 











Amount 


passed out in the faeces of 


Food. 


Dry sub- 


Albu- 




Carbo- 




stance 


men (N.) 


Fat 00. 


hydrates 




(%). 


(*), 




00. 


Roast beef 


5 06 


2.65 


19.2 




Eggs • 








5-2 


2.9 


5.o 




Milk . 








9.1 


8.9 


5-7 


O 


White bread 








4.4 


20.7 




I.I 


Black bread 








15-0 


32.0 




10.9 


Pastry 








4.9 


20.5 




1.6 


Rice . : 








4.1 


20.4 




0.9 


Potatoes 








9.4 


32.2 




7.6 


Vegetables 








14.9 


18.5 


6.1 


15.4 


Peas . 








11. 8 


22.6 




5-3 


Fat (100 grams [3 ounces] 










of bacon) 


8-5 


12. 1 


17.4 


1.6 



Finally, may be added a list of important factors neces- 
sary for calculation in the experiment of metabolism : 
Nitrogen : Urea = 1 : 2.143. 
Nitrogen : Albumen = 1 : 6.25. 
Nitrogen : Muscular substance = 1 : 29.4. 
Urea : Nitrogen = 1 : 0.466. 
Urea : Albumen — 1 : 2.9. 
Urea : Muscular substance == 1 : 13.71. 
Muscular substance : Nitrogen = 1 : 0.034. 
Albumen : Nitrogen = 1 : 0.16. 



Table of the Weights of the Human Body, 
male. 



Age, 


Height in ft. and inches. 


Weight. 




At birth. 


1 ft. 


7 in. 


"0.496 m." 




7 lbs. 


" 3.20 kg.] 




I year. 


2 ft. 


3 m. 


0.696 m. 




22 " 


10.00 " 




2 " 


2 ft. 


8 in. 


0.797 m. 




26 " 


12.00 " 




3 " 


2 ft. 


g in. 


0.860 m. 




29 " 


13.21 " 




4 " 


3 ft. 




0.932 m. 




33 " 


15.07 " ; 




5 " 


3 ft. 


3 in. 


0.990 m. 




36 " 


16.70 " \ 




6 " 


3 ft. 


5 in. 


1.046 m.° 




39 " 


^18.04 " \ 




7 " 


3 ft. 


8 in. 


1. 112 m. 




44 " 


20.16 ti 




8 " 


3 ft. 


9 in. 


1. 170 m/ 




49 " 


22.26 " ' 




9 " 


4 ft. 




1 227 m.' 




53 " 


L 24.09 " ' 




10 " 


4 ft. 


2 in. 


^1.282 m. 




57 " 


^26. 12 " ] 




12 " 


4 ft. 


6 in. 


[1.359 m/ 




68 " 


'31.00 ** \ 
"40.50 <k 




14 " 


4 ft. 


10 in. 


L i.4S7 m. 




89 » 




16 " 


5 ft. 


3 in. 


1. 610 m. 




117 " 


.53-39 " . 




18 " 


5 ft. 


6 in. 


"1.700 m v 




135 " 


61.26 " 




20 " 


5 ft. 


8 in. 


1. 711 m. 




143 " 


"65.00 " ; 




25 " 


5 ft. 


9 in. 


1.722 m. 




150 " 


= 68.2 9 <( = 




30 " 


5 ft. 


9 in. 


"1.722 m." 




152 " 


^68.90 " = 




40 " 


5 ft. 


8 in. 


[1.713 m.\ 




151 " 


"68.81 " = 




50 ■« 


5 ft. 


6 in. 


1.674 m - 




148 " 


= 67-45 li ' 




60 " 


5 ft- 


5 in. 


1.664 m - 




144 " 


^65.50 " 





FEMALE. 



Age. 



At birth. 

1 year. 

2 " 

3 " 

4 " 

5 " 

6 " 

7 " 

8 " 

9 

10 " 

12 " 

14 " 

16 " 

18 " 

20 " 

25 " 

30 " 

40 " 

60 " 



Height in ft. and inches. 



ft. 

ft. 

ft. 

ft. 

ft. 

ft. 

ft, 

ft. 

ft, 

ft. 

ft. 

ft. 

ft. 

ft. 

ft. 

ft. 

ft. 
5 ft. 
5 ft- 
5 ft. 



6 in. 

3 in. 

6 in. 
9 in. 

2 in. 

4 in. 

7 in. 
9 in. 

11 in. 

I in. 

4 in. 

9 in. 
11 in. 

1 in. 

2 in. 
2 in. 
2 in. 
1 in. 



"0.4S3 m." 


0.690 m. 


O 780 m. 


0.850 m. 


0.910 m. 


0.974 m 


1.032 m. 


1.096 m. 


1. 139 m. 


1.200 m. 


1.248 m. 


1.327 m. 


1.447 m. 


1.500 m. 


1.562 m. 


1.570 m. 


1.577 m. 


1-579 m. 


.1-555 m. 


1. 516 m. 



Weight. 



6 lbs. 


2.91 kg. J 


20 " 


9.30 ' 




25 " 


11.40 ' 




27 " 


12.45 « 




31 " 


14.18 ' 




34 " 


15.50 ' 




37 " 


16.74 ' 




40 " 


18.45 ' 




43 " 


19.82 ' 




50 " 


22.44 ' 




53 " 


24.24 ' 




67 " 


.30.54 ' 




84 " 


38.10 ' 




98 " 


r 44-44 ' 




117 " 


53- 10 ' 




120 " 


.54-46 ' 




121 " 


55.08 ' 




121 " 


55-14 ' 




129 " 


5S.45 ' 




125 " 


.56.73 ' 





144 



CLINICAL DIAGNOSIS. 



DOSE TABLE. 
[The doses given are for adults. For hypodermic use 
the dose should be one half, and for use by the rectum, 
twice that by the mouth. The dose for children is calcu- 
lated by adding 12 to the age of the child, and divid- 
ing by the age, thus : for a child 4 years old the dose 
would be ^-^ = 4 or J- of the dose for adults. The 
doses are given in terms, both of the Apothecaries' and 
of the Decimal metric system. 







Dose expressed 








in terms of 


Dose 




Remedies. 


apothecaries' 


expressed in 






weights 


metric terms. 






and measures. 




Acet 


colchici . . 


f 3 ss to 3 i 


2 to 4 ccm. 


4< 


lobeliae . 






TT[ xv to lx 


I to 4 ccm. 


" 


opii 






TTJ, V tO X 


0.30 to 0.60 ccm. 


< < 


sanguinar. 






TTJ, XV to XX 


1 to 2 ccm. 


< < 


scillse 






TTj, x to XXX 


0.60 to 2 ccm. 


Acid 


. acet. dil. 






ux lx to XC 


4 to 6 ccm. 


" 


arsenios. 






g r - 6¥ l ° 12 


0.001 to 0.005 g m - 


" 


benzoic. 






gr. v to xv 


0.30 to 1 gm. 


" 


boracic. 






gr. v to x 


0.30 to 0.60 gm. 


" 


carbolic. 






gr. j to iii 


0.05 to 0.20 gm. 


" 


gallic. 






gr. iij to xv 


0.20 to I gm. 


" 


gall, in albuminuria 






gr. x to lx 


0.60 to 4 gm. 




hydrobrom. (34 %) . 






gr. x to xv 


0.60 to T gm. 


" 


hydrobrom. dil. 






"HI xv to xl 


1 to 4 ccm. 




hydrochlor. dil. 






Tit x to XXX 


0.60 to 2 ccm. 


" 


hydrocyan. dil. 






Tfl ij to vj 


0.10 to 0.40 ccm. 


" 


lactic. 






gr. xv to lx 


I to 4 gm. 


" 


nitr. dil. 






TTt x to XXX 


0.30 to 2 ccm. 


" 


nitro-hydrochlor. dil. 






V\ V to XX 


0.30 to 1.20 ccm, 


" 


phosphoric. (50 %) . 






gr. iij to v 


0.20 to 0.30 gm. 


it 


phosphoric, dil. 






TTi x to lx 


0.60 to 4 ccm 


11 


salicyl. . 






gr. v to xv 


0.30 to 1 gm. 


1 i 


sulphuric, dil. 






TH v to XXX 


0.30 to 2 ccm. 


" 


sulphuric, arom. 






TTL v to XXX 


0.30 to 2 ccm. 


" 


sulphuros. 






TT[ xxx to lx 


2 to 4 ccm. 


" 


tannic. . 






gr. ij to x 


0.10 to 0.60 gm. 



DOSE TABLE. 



'45 





Dose expressed 






iu terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Aconitina (white crystals) 


S r - 400" to ^0(5" 


0.00015 to 0.0005 g m > 


Adonidine .... 




gr. f<; to i 


0.06 to 0.02 gm. 


Aloe 








gr. ii to v 


0. 10 to 0.30 gm. 


Aloe et canella 








gr. v to xxx 


0.30 to 2.0 gm. 


Aloinum 








gr. j to iij 


c.06 to 0.20 gm. 


Alumen (expectorant 


) 






gr. iij to x 


0.20 to 0.60 gm. 


" exsiccat. 








gr. v to xxx 


0.30 to 2 gm. 


Ammonii benzoas 








gr. x to xx 


0.60 to 1.2 gm. 


" bromid. 








gr. v to xxx 


0.30 to 2 gm. 


" carb. 








gr. iij to x 


0.20 to 0.60 gm. 


" chlorid. 








gr. xv to xxx 


1 to 20 gm. 


" iodid. 








gr. iij to xv 


0.20 to 1.0 gm. 


' ' phosph . 








gr. v lo xx 


0.30 to 1.2 gm. 


" picras 








gr. itoi 


0.15 to 03 gm. 


" sulph. 








gr. iij to xv 


0.20 to 1.0 gm. 


" valer. 








gr. iij to xv 


0.20 to 1.0 gm. 


Amyl nitris 








TTL ij to V 


0. 10 to 0.30 gm. 


Anthemis 








3 ss to 3 j 


2.0 to 4.0 gm. 


Antimonii et pot. tartr. (diapli.) 




g r - tV to h 


0.004 to 0.01 gm. 


" et pot. tartr. (emetic) 




gr. j to ij 


0.05 to 0.10 gm. 


" oxid. 




gr. j to ij 


O.05 to 0. 10 gm. 


oxysulphurct. 






gr. i to ii 


0.03 to 0.10 gm. 


sulphid. . 






gr. i to ij 


0.03 to 0.01 gm. 


" sulphuret. 






gr. -i- to n 


03 to 0. 10 gm. 


Antipyrine 






gr. v to xv 


30 to 1.0 gm. 


Apomorph. hydrochlor. 






g'-- ifo to T V 


0.002 to 0.005 gm. 


Aqua ammoniae 






TTL VJ tO XXX 


0.40 to 2 ccm. 


" amygd. amar. 






f 3 ij to xv 


8.0 to 16.0 ccm. 


' ' camphorse 






f \ ss to ij 


15 to 60 ccm. 


" chlori 






f 3 j to iv 


4 to 15 ccm. 


" creasoti . 






f 3 j to iv 


4 to 15 ccm. 


" laurocerasi 






Tfyvj to xxx 


0.40 to 2 ccm. 


Argenti iodidum 






gr. \ to ij 


0.03 to 0.10 gm. 


" nitras . 






g'-. \ to A 


0.01 to 0.02 gm. 


" oxid. . 






gr. -J to ij 


0.03 to 0.10 gm. 


Arnica 






gr. v to xx 


0.30 to 1.20 gm. 


Arsenici iodidum 






g r - 6T tO T V 


0.001 to 0.005 gm. 


Asafcetida 






gr. v to xx 


0.30 to I.20 gm. 


Atropina 






gr. T ^ to J 5 


0.005 to 0.002 gm. 


Atropinae sulph. 








gr . y |- to 5*2 


0.005 to 0.002 gm. 



146 



CLINICAL DIAGNOSIS. 





Dose expressed 






in teims of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Auri et sodii chlorid. 


gr. 3L to T V 


0.002 to 0x04 gm. 


Belladonnas folium . 








g r - j 


0.05 gm. 


Bismuthi citras 








gr. iij to xv 


0.20 to 1.0 gm. 


" et ammon. citr. 








gr. j to xv 


O.05 to 1.0 gm. 


" sub-carb. . 








gr. vj to xxx 


0.40 to 2 gm. 


" sub-nitr. 








gr. vj to xxx 


0.40 to 2 gm. 


" tannas 








gr. vj to xxx 


O.40 to 2 gm. 


4 ' valer. 








gr. j to iij 


0.05 to 0.20 gm. 


Brucina . 








g r - -h lo iV 


0.001 to 0.004 gm° 


Buchu 








gr. xx to xxx 


1.20 to 2.0 gm. 


Caffeina . 








gr. j to v 


0.05 to 0.30 gm. 


Caffeinse citras 








gr. j to v 


O.05 to 0.30 gm. 


Calcii bromidum 








gr. v to xxx 


0.30 to 2.0 gm. 


" carb. 








gr. xv to Ix 


1 to 4 gm. 


" hypophosphis 








gr. iij to xv 


0.20 to 1 gm. 


" iodidum 








gr. j to iij 


0.05 to. 0.20 gm. 


84 phosphas 








gr. xv to xxx 


1 to 2 gm. 


Calumba 








gr. x to xxx 


0.60 to 2.0 gm. 


Calx sulphurata 








g r - -3- to j 


0.02 to 0.05 gm. 


Cambogium 








gr. 1 to iv 


05 to 0.25 gm. 


Camphora 








gr. iij to x 


O.20 to 0.60 gm. 


Camph. monobrom. 








gr. ij to v 


0.10 to 0.30 gm. 


Cantharis 








gr. \ to ij 


0.03 to 0.10 gm. 


Cardamonum . 








gr. v to xxx 


O.30 to 2 gm. 


Castoreum 








gr. vj to xv 


0.40 to I gm. 


Catechu . 








gr. xv to xxx 


1 to 2 gm. 


Cerii nitras 








gr. j to iij 


0.05 to O.20 gm. 


" oxalas 








gr-'j to iij 


0.05 to 0.20 gm. 


Chinoidinum . 








gr. iij to xxx 


O.20 to 2 gm. 


Chloral hydrat. 








gr. iij to xv 


0.20 to 1 gm. 


Chloroformum 








TTLJ to V 


O.05 to 0.30 ccm„ 


Cinchona 








gr. xv to lx 


I to 4 gm. 


Cinchonidina and its salts 








gr. j to xxx 


0.05. to 2 gm. 


Cinchonina and its salts 








gr. j to xxx 


0.05 to 2 gm. 


Cinnamonum . 








gr. vj to xxx 


0.40 to 2 gm. 


Codeina . 








gr. | to ij 


0.03 to 0.10 gm. 


Colchici radix . 








gr. ij to vj 


0.03 to 0.40 gm. 


" semen 








gr. ij to vj 


0.03 to 0.40 gm. 


Colocynthis 








gr. v to xv 


0.30 to 1.0 gm. 


Confectio opii . 








gr. x to xx 


0.C0 to i.co gm. 



DOSE TABLE. 



H7 





Dose expressed 




Remedies. 


in terms of 
apothecaries' 
weights and 


Dose expressed in 
metric terms. 








measures. 




Confectio sennse .... 


gr. j to ij 


0.5 to 0.10 gm. 


Conii fol. 






gr. 11 j 


0.20 gm. 


Coniina and its salts 






gr. J3- to & 


0.001 to 0.002 gm. 


Copaiba . 






TT[ xv to lx 


1 to 4 ccm. 


Creasotum 






Til j to iij 


0.05 to 0.20 ccm. 


Creta prsepar. 






gr. xy to Ixxv 


1 to 5 gm. 


Croton chloral 






gr. j to x 


0.05 to 0.60 gm. 


Cubeba . 






gr. xv. to lx 


1 to 4 gm. 


Cupri acetas 






g r - \ to vj 


0.03 to 0.40 gm. 


" sulphas . 






gr. \ to x 


0.03 to 0.60 gm. 


Cuprum aramon. 






g r - i to j 


o.oi to 0.05 gm. 


Curare 






g 1 "- T2 tO_i 


0.002 to 0.01 gm. 


Decoct, aloes comp. 






f 1 ss to ij 


15 to 60 ccm. 


" chimaphilge 






fjij 


60 ccm. 


" citron se 






flij 


60 ccm. 


" sarsap comp. 






f I ij to vj 


50 to 200 ccm. 


Digitalinum 






gr. fo to 3L 


0.001 to 0.002 gm. 


Digitalis . 






gr. \ to ij 


0.03 to 0. 10 gm. 


Duboisina and its salts 






g 1 "- ih to eV 


0.0005 to O.ooi gm. 


Elaterinum, U. S. P., 1880 




g r - -arV to re 


0.001 to 0.004 g m - 


Elaterium " 1870 




gr. tV to \ 


0.004 t0 °-°3 g m - 


Emetina and salts, (emetic) 




gr- f to i 


0.008 to 0.016 gm. 


" and salts, (diaph.) 




gr. j^js to ¥ V 


0005 to 0.002 gm. 


Ergot a ..... 




gr. xv to lx 


1 to 4 gm. 


Ergotinum .... 




gr. ij to viij 


0.10 to 0.50 gm. 


Eserinse and its sails 




gr- 6T to Ffr 


0.001 to 0.004 gm. 


Extr. absinthii fl. 




TT[ xv to XXX 


1 to 2 ccm. 


" aconiti fol. (Engl.) . 




gr. 3 to j 


0.02 to O.05 gm. 


" aconiti fol., U. S. P., 1870 




gr- i to ij 


0.03 to 0.10 gm. 


" aconiti fol. fluid. 




TTl i to V 


0.05 to 0.30 ccm. 


" aconiti rad., U. S. 1'., 1880 




gr- tV to i 


0.005 to 0.015 gm. 


" aconiti rad. fluid 




m i to ijss 


0.03 to 0.13 ccm. 


" agaric fl. .... 




Tit v to XX 


0.30 to 1.20 ccm. 


" aloes aquos. .... 




gr. \ to iij 


O.03 to 0.20 gm. 


" anthemidis .... 




gr. ij to x 


0. 10 to 0.60 gm. 


" anthemidis fl. ... 




TTT, XXX to lx 


2 to 4 ccm. 


" arnicse flor. .... 




gr. iij to viij 


0.20 to 0.50 gm. 


" arnicse fl. .... 




TTL v tO XV 


0.30 to 1 ccm. 


" arnicae rad. . ... 




gr. ij to v 


0. 10 to 0.30 gm„ 


" arnicae rad. fl. 






TTL v to xv 


0.30 to 1 ccm. 



148 



CLINICAL DIAGNOSIS. 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Extr. aromat. fl. . . 


TIL xxx to lx 


2 to 4 ccm. 


" aurantii. cort. fl. 








f 3 i to ijss 


1 to 10 ccm. 


" bellad. fol. (Engl.) 








gr- *tof 


0.01 to 0.04 gm. 


" bellad. alcohol 








gr. <t to£_ 


0.01 to 0.03 gm. 


44 bellad. fol. fl. 








TTj, i i j to VJ 


0.20 to 0.40 ccm. 


" bellad. rad. 








gr. i to i 


O.008 to 0.016 gm. 


44 bellad. rad. fl. 








TTL j to iij 


0.05 to 0.20 ccm. 


44 berber. aquifol. fl. 








TTL xv to xxx 


1 to 2 ccm. 


44 berber. vulg. fl. 
44 brayerae fl. 








TTL XV tO XXX 


1 to 2 ccm. 








f 3 ij to iv 


8 to 16 ccm. 


44 bryonise fl. 








ttl xv to lx 


1 to 4 ccm. 


44 buchu fl. 








f 3 ss to ijss 


2 to 10 ccm. 


14 calami, fl. 








ttl xv to lx 


1 to 4 ccm. 


44 calend. fl. 








TTL xv to lx 


1 to 4 ccm. 


44 calumbse 








gr. iij to x 


0.20 to 1.20 gm. 


44 calumbse fl. 








TTL xv to lx 


1 to 4 ccm. 


44 cannab. Amer. fl. 








TTL iij to xv 


0.20 to 1 ccm. 


41 cannab. ind. . 








gr. | to \ 


o.oi to 0.03 gm. 


44 cannab. ind. fl. 








TTL i'j to vj 


0.20 to O.40 ccm. 


" cantharidis fl. 








TTL j to iij 


0.05 to 0.20 ccm. 


44 capsici fl. 








ttl j to iij 


0.05 to O.20 ccm. 


44 cardam. comp. fl. 








TTL XV to xlv 


1 to 3 ccm. 


44 carnis 








gr. xv to lx 


I to 4 gm. 


44 cascarillae fl. . 








f 3 f to ijss 


3 to 10 ccm. 


44 castaneae fl. 








f 3 f to ijss 


3 to 10 ccm. 


44 catechu liquid. 








TTL viij to xxx 


0.50 to 2 ccm. 


44 caulophylli fl. 








TTL xv to xxx 


1 to 2 ccm. 


44 cimicifugse fl. . 








TTL viij to xxx 


0.50 to 2 ccm. 


44 cinchonas 








gr. xv to xxx 


1 to 2 gm. 


41 cinchona? fl. 








TTL xxx to lx 


2 to 4 ccm. 


44 cinchonas arom. fl. 








ttl xxx to lx 


2 to 4 ccm. 


44 cinchonae comp. fl. 








f 3 ss to jss 


2 to 6 ccm. 


44 colch. rad. 








gr. 1 to i| 


0.02 to 0.08 gm. 


44 colch. rad. fl. . 








TTL iij to xv 


0.20 to 1 ccm. 


44 colch. sem. fl. 








TTL I^- tO X 


O.08 to 1.20 ccm. 


44 colocynth 








gr. i-J- to v 


0.08 to 0.30 gm. 


44 colocynth comp. 








gr. ii to v 


0.08 to 0.30 gm. 


44 condurango fl. 








TTL viij to xxx 


0.50 to 2 ccm. 


44 conii fol. (Engl.) 








gr. j to iv 


0.05 to 0.25 gm. 


44 conii fol. ale, U. !; 


>. P., 


1870 




gr. 1 to li 


0.05 to 0.08 gm. 



DOSE TABLE. 



149 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Extr. eon. (fr.)alc, U. S. P., 1880 . 


gr-itoj 


0.02 to 0.05 gm. 




' conii fol. fl. . 




TTJ, iij to XV 


0.20 to 1 ccm. 




' con. (fr.) fl. U. S. P., 1880 




TT^ l| tO V 


03 to 0.30 ccm. 




' convallariae rad. fl. . 




TTL XV to XXX 


1 to 2 ccm 




' cubebse fl. 








VI XV IO XXK 


1 to 2 ccm. 




' damianae fl. 










f 3 ss to ijss 


2 to 10 ccm. 




' delphinii fl. 










TTi j to iij 


0.05 to 0.20 ccm. 




' digitalis . 










gr. i lo i 


0.01 to 0.03 gm. 




1 digitalis fl. 










Hi 1 to vj 


0.05 to 0.40 ccm. 




' duboisiae 










gr- i to | 


0.015 to 0.03 gm. 




' duboisiae fl. 










TTJ, v tO X 


0.30 to 1.20 ccm. 




1 dulcamarae 










gr. v. to xv 


0.30 to 1 gm. 




' dulcamarae fl. 










f 3 j to ij 


4 to 8 ccm. 




1 ergotae . 










gr. iss to viij 


0.08 to 0.5 gm. 




' ergotae fl. 










TTI, xv to Ix 


1 to 4 ccm. 




' erythroxyli fl. 










f 3 ss to ij 


2 to 8 ccm. 




' eucalypti fl. 










TTI, xv to lx 


1 to 4 ccm. 




' euonymi fl. 










TTI XV tO lx 


I to 4 ccm. 




' eupatorii fl. 










TTX XXX tO lx 


2 to 4 ccm. 




' euphorb. ipec. 


fl. 








TTj, V tO XXX 


0.30 to 2 ccm. 




1 ferri. pom. 










gr. iij to xv 


O.20 to I gm. 




1 frangulae fl. 










f 3 ss to ijss 


2 to 10 ccm. 




1 fuci vesiculos. 










V\ xv to XXX 


1 to 2 ccm. 




' gallae fl. 










f 3 ss to ij 


2 to 8 ccm. 




' gelsemii . 










TTj, ij to viij 


0.10 to 0.50 ccm. 




' gelsemii fl. 










TTI j to viij 


0.05 to 0.50 ccm. 




1 gent. fl. . 










TTL XXX to lx 


2 to 4 ccm. 




' gent. comp. fl 










TTj, XXX tO lx 


2 to 4 ccm. 




' geranii fl. 










TTX XV tOO XXX 


1 to 2 ccm. 




1 gossypii fl. 










TTi XV tO xlv 


1 to 3 ccm. 




1 granati. rad. cort. fl 








f 3 ss to ij 


2 to 8 ccm. 




1 grind, rob. fl. 








TTj, XXX tO lx 


2 to 4 ccm. 




1 guaiaci ligni fl. 








TTi XXX tO lx 


2 to 4 ccm. 




' guaranae fl. 








TT1, XV tO XXX 


1 to 2 ccm. 




' haematoxyli 








gr. v to xxx 


0.30 to 2 gm. 




' haematoxyli fl. 








Til XXX tO lx 


2 to 4 ccm. 




1 hamamelid fl. . 








ttl xxx to xc 


2 to 6 ccm. 




c helieb. nigris . 








gr. i to iij 


0.03 to 0.20 gm. 




1 helieb nigris fl. 








TTj, V tO XV 


0.30 to 1 ccm. 




1 humuli . 










gr. iij to xv 


0.20 to I gm. 



i5o 



CLINICAL DIAGNOSIS. 





Dose expressed 








in terms of 


Dose 




RemedieSo 


apothecaries' 


expressed in 






weights 


metric terms. 






and measures. 






Extr. humuli fl. 


TTj, iij to XV 


0.20 to 1 ccm. 






' hydrangeas fl. 






TTJ, xxx to Ix 


2 to 4 ccm. 






' hydrastis 






gr. iij to x 


0.20 to 1.20 gm. 






' hydrastis fl. . 






n^ v to xxx 


O.30 to 2.0 ccm. 






' hyoscyami (Engl.) . 






gr. j to iv 


0.05 to 0.25 gm. 






* hyoscyami ale. 






gr. j to ij 


0.05 to 0.10 gm. 






' hyoscyami fol. fl. 






TT[ iij to xv 


0.20 to 1 ccm. 






' hyoscyami sem. fl. . 






TTj, ij to viij 


0.10 to 0.50 ccm. 






' ignatiae . 






gr. i to ii 


0.02 to 0.65 gm. 






' ignatiae fl. 






m j to vj 


0.05 to 0.40 ccm. 






' ipecac fl. 






VI iij to lx 


0.20 to 4 ccm. 






' iridis versicol. 






gr. iij to vj 


0.20 to 0.40 gm. 






' iridis versicol fl. 






TIL «xv too xxx 


1 to 2 ccm. 






' jalapse, U. S. P., 1870 






gr. v tox 


0.30 to 0.60 gm. 






' jalapse ale. 






gr. iij to vj 


0.20 to 0.40 gm. 






' jalapae fl. 








TT[ xv to lx 


1 to 4 ccm. 






' junip. fl. 








TTJ, xxx to lx 


2 to 4 ccm. 






' kamala fl. 








Til, xxx to lx 


2 to 4 ccm. 






' kino liquid 








Til, xv to xxx 


1 to 2 ccm. 






' kramarise 








gr. v to xv 


0.30 to 1 gm. 






1 lactucse fl. 








TH, xv to lx 


1 to 4 ccm. 






' lactucarii fl. 








TIX v to xxx 


0.30 to 2.0 ccm. 






' leptandrse 








gr. iij to x 


O.20 to 0.60 gm. 






' leptrandrae fl. 








TTL XXX to lx 


2 to 4 ccm. 






' lobeliae fl. 








TTi j tO V 


0.05 to 0.30 ccm 






' lupulini fl. 








TTj, V to XV 


0.30 to 1 ccm. 






' matico fl. 








TTi, xxx to lx 


2 to 4 ccm. 






' myricae fl. 








TTj, xxx to lx 


2 to 4 ccm. 






' nectandrae fl. 








f 3 j to iv 


4 to 16 ccm. 






' nuc. vom. 








gr. i to i| 


0.02 to 0.08 gm. 






' nuc. vom. fl. 








ttl 1 to iv 


0.05 to 0.30 ccm. 






' opii 








gr- £ to | 


0.01 to 0.03 gm. 






* papaveris 








gr. i to ij 


0.03 to 0.10 gm. 






' papaveris fl. 








TT], XV tO xlv 


1 to 3 ccm. 






1 pareirae fl. 








TTj, xxx to lx 


2 to 4 ccm. 






4 petroselini fl. 








f 3 j to ij 


4 to 8 ccm. 






' physostigmce 








gr. tV to I 


0.004 to 0.01 gm. 






' physostigmae fl. 






TTI j to iij 


0.05 to 0.20 ccm. 






4 phytolaccae baccar. fl. 






TT[V tO XXX 


0.30 to 2 ccm. 






' phytolaccae rac 


I. 






gr. j to iij 


0.05 to 0.20 gm. 





DOSE TABLE. 



151 





Dose expressed 






in terms of 


Dose 


Remedies. 


■ apothecaries' 


expressed in 




weights and 


metric terms. 




measures. 




Extr. phytolaccae rad. fl. . 


TT^v to XXX 


0.30 to 2 ccm. 




' pilocarpi fl. 








TTl,XV tO lx 


1 to 4 ccm. 




' pimentae fl. 








TTLxv to xlv 


1 to 3 ccm. 




' piper nigr. fl. . 








TIL xv to xlv 


I to 3 ccm. 




' podophylli 








gr. £ to i£ 


0.03 to 0.08 gm. 




' podophylli fl. . 








TTLv to XXX 


0.30 to 2.0 ccm. 




' polygoni fl. 








TTLxv to XXX 


I to 2 ccm. 




' polygonati fl. . 








TILV tO XV 


0.30 to I ccm. 




1 prun. virg. fl. . 








TTLxxx to lx 


2 to 4 ccm. 




1 quassias . 








gr. j to v 


0.05 to O.30 gm. 




' quassiae fl. 








TTLxxx to lx 


2 to 4 ccm. 




' quebracho fl. . 








TTLX tO lx 


0.60 to 4 ccm. 




' quercus fl. 








TTLxxx to lx 


2 to 4 ccm. 




' rhamni cath. ft. fl. 






TTLxxx to lx 


2 to 4 ccm. 




4 rhamni pursh. cort. fl. 






TTLxxx to exx 


2 to 8 ccm. 




' rhei 






gr. v to xv 


0.30 to 1 gm. 




« rheifl. . 








TTLxv to xlv 


1 to 3 ccm. 




' ricini fol. fl. . 








f 3 ss to ij 


2 to 8 ccm. 




' rutae fl. . 








TTLxv to xxx 


I to 2 ccm. 




' sabinae fl. 








TTLv to XV 


0.30 to 1 ccm. 




' sanguin. fl. 








TTLV tO XV 


0.30 to 1 ccm. 




' santali citr. fl. 








f 3 j to ij 


4 to 8 ccm. 




' santonicae fl. . 








TTLxv to lx 


1 to 4 ccm. 




' sarsap. fl. 








f 3 ss to ij 


2 to 8 ccm. 




' sarsap. comp. fl. 








f 3 ss to ij 


2 to 8 ccm. 




' sassafras fl. 








f 3 ss to ij 


2 to 8 ccm. 




' scillae fl. . 








TTLV to XXX 


0.30 to 2 ccm. 




' scillae comp. fl. 








TTLV tO XXX 


0.30 to 2 ccm. 




' scoparii fl. 








f 3 ss to j 


2 to 4 ccm. 




' senegae fl. 








TTLV tO XV 


0.30 to 1 ccm. 




' sennae fl. 








f 3 j to iv 


4 to 16 ccm. 




' serpent, fl. 








TTLxxx to lx 


2 to 4 ccm. 




' simarubae fl. 








TTLxv to XXX 


1 to 2 ccm. 




' spigeliae fl. 








TTLxv to lx 


I to 4 ccm. 




1 spigeliae et sennae fl 








f 3 ss to ij 


2 to 8 ccm. 




' stillingiae fl. . 








f 3 ss to ij 


2 to 8 ccm. 




1 stillingiae comp. 








f 3 ss to ij 


2 to 8 ccm. 




1 stramonii (Engl.) 








gr. i to j 


0.03 to 0.05 gm. 




* stramonii fol. ale. 








gr. i to 1 


0.02 to 0.04 gm. 




' stramonii sem. 








gr. i to i 


0.01 to 0.03 gm. 



i=;2 



CLINICAL DIAGNOSIS. 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Extr. stramonii fl. . 


TT^j to vi 


0.05 to 0.40 ccm. 


" sumbul fl. 








TTJ,XV to lx 


1 to 4 ccm. 


" taraxaci . 








gr. v to xv 


O.30 to I gm. 


" taraxaci fl. 








f 3 ss to ij 


2 to 8 ccm. 


" toxicodendri fl. 








Taj to v 


O.05 to O.30 ccm. 


" trifol. prat. fl. 








f 3 j to ij 


4 to 8 ccm. 


" urticse rad. fl. . 








v\v to xv 


0.30 to I ccm. 


" ustilag. maid. fl. 








TTIXV to lx 


1 to 4 ccm. 


" uva? ursi fl. 








TT^xxx to lx 


2 to 4 ccm. 


" valer. 








gr. v to xv 


0.30 to I gm. 


" valer. fl. 








TTlxxx to lx 


2 to 4 ccm. 


" veralr. vir. fl. 








TT[ij to viij 


0.10 to O.50 ccm. 


" verbense fl. 








TT[XV to lx 


I to 4 ccm. 


" viburni opuli fl. 








i 3 j to ij 


4 to 8 ccm. 


" viburni [prunifol] fl 








i 3 j to ij 


4 to 8 ccm. 


" yerbse santae fl. 








i 3 i to 3 j 


1 to 4 ccm. 


" zingiberis fl. 








TI[v to XXX 


0.30 to 2 ccm. 


Ferri arsen. 








gr. ¥ V to i 


O.003 to 0.03 gm. 


" benzoas . 








gr. j to v 


0.05 to 30 gm. 


" bromid. . 








gr. j to v 


0.05 to 0.30 gm. 


" carb. sacch. 








gr. iv to xv 


0.25 to I gm. 


" chlorid. . 








gr. j to iij 


0.05 to 0.20 gm. 


" citr. 








gr. v to x 


0.30 to 0.60 gm. 


" et ammon. citr. 








gr. v to x 


0.30 to 0.60 gm. 


" et ammon. sulph. 








gr. v to x 


0.30 to 0.60 gm. 


" et ammon. tartr. 








gr. v to xv 


0.30 to I gm. 


" et cinchonid. citr. 








gr. v to x 


0.30 to 0.60 gm. 


1 ' et pot. tartr. . 








gr. xv to lx 


I to 4 gm. 


" et quin. citr. . 








gr. v to x 


0.30 to 0.60 gm. 


" et strychnin, citr. 








gr. j to xv 


0.05 to I gm. 


" ferrocyanid. 








gr. iij to v 


0.20 to 30 gm. 


44 hypophosphis . 








gr. v to x 


0.30 to 0.60 gm. 


44 iodidum . 








gr. j to v 


0.05 to O.30 gm. 


" iodidum sacch. 








gr. ij to x 


0. 10 to 0.60 gm. 


" lactas 








gr. j to iij 


0.05 to 0.20 gm. 


44 oxalas 








gr. j to iij 


0.05 to 0.20 gm. 


" oxid. hydrat. . 








I ss to ij 


15 to 60 ccm. 


" oxid. magnet. 








gr. v to x 


0.30 to 0.60 gm. 


" phosphas 








gr. j to v 


0.05 to 0.30 gm. 


" hypophosphas 








gr. j to v 


0.05 to 0.30 gm. 



DOSE TABLE. 



153 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Fcrri sub-carb. .... 


gr. v to xxx 


0.30 to 2 gm. 


" sulphas . 








gr. j to iij 


0.05 to 0.20 gm. 


" sulphas exsiccat. 








gr. \ to \\ 


0.03 to O.08 gm. 


" valer. 








gr. j to iij 


0.05 to O.20 gm. 


Ferrum ammoniat. . 








gr. v to x 


0.30 to 0.60 gm. 


" dialys. 








THj to XV 


0.05 to I ccm. 


" redact. 








gr. j to v 


0.05 to 0.30 gm. 


Filix mas 








3 j to ij 


4 to 8 gm. 


Fuchsine . 








gr. j to iij 


0.05 to 0.20 gm. 


Galla 








gr. x to xx 


0.60 to 1.20 gm. 


Gambogia 








gr. ij to iij 


0.10 to O.20 gm. 


Gentiana 








gr. x to xxx 


0.60 to 2 gm. 


Guarana . 








gr. v to xxx 


0.30 to 2 gm. 


Hydrarg. c. creta 








gr. v to x 


0.30 to 0.60 gm. 


" chlor. corros. 








gr. ci- to jV 


O.OOI to 0.005 gm. 


" chlorid. mite 








gr. \ to vnj 


O.oi to 0.50 gm. 


" cyanid. 








gr- h to £ 


0.004 to O.03 gm. 


" iodid. flav. 








g r - \ to j 


o.oi to O.05 gm. 


" iodid. rubr. 








g r - h to £ 


0.004 to 0.03 gm. 


" iodid. vir. 








g r - \ to j 


0.01 to 0.05 gm. 


" oxid. flav. 








gr- tV to £ 


0.004 to 0.03 gm. 


" oxid. nigr. 








gr- iV l0 J 


0.005 to 0.05 gm. 


" oxid. rubr. 








gr- iV to £ 


0.004 to 0.03 gm. 


" subsulphas flav. 






gr. i to j 


0.015 to 0.05 gm. 


" sulphuret. nigr. 






gr. v to x 


0.30 to 0.60 gm. 


" sulphuret. rub. 






gr. v to x 


0.30 to 0.60 gm. 


" c. magn. . 






gr. v to x 


0.30 to 0.60 gm. 


Infusum brayeroe 








1 1 ij to viij 


60 to 250 ccm. 


" buchu 








f§ij 


60 ccm. 


" digitalis 








f 3 ij to iv 


8 to 16 ccm. 


" eupatorii 








f Iij 


60 ccm. 


" sennce comp. 








f 1 j to ij 


30 to 60 ccm. 


" ulmi . 








Ad libitum-. 


Ad libitum. 


Iodinum . 








gr. i to j 


0.015 to O.05 gm. 


Iodoform urn 








gr. j to iij 


0.05 to 0.20 gm. 


Ipecacuanha expect. 








gr- I to j 


0.01 to 0.05 gm. 


emet. . 








gr. xv to xxx 


1 to 2 gm. 


Jalapa 








gr. xv to xxx 


1 to 2 gm. 


Juniperi baccce 








3 j to ij 


4 to 8 gm. 


Kairine . 








rr. ij to x 


0. 10 to 0.60 gm. 



154 



CLINICAL DIAGNOSIS. 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Kino ...... 


gr. x to xxx 


o.6o to 2 gm. 


Krameria ..... 


gr. x to xxx 


o.6o to 2 gm. 


Lacto-peptine ..... 


gr. x _ 


o.6o gm. 


Lactucarium ..... 


gr. iij to x 


0.20 to o.6o gm. 


Liq. ammon. acet. .... 


f 3 ij to viij 


8 to 25 ccm. 


" acidi arseniosi .... 


TTlij to vij 


0. 10 to 0.50 ccm. 


' ' arsen. et hydr. iod. (Donovan's sol.) 


niij to vij 


0. 10 to 0.50 ccm. 


" ferri chloridi .... 


TT^ij to X 


0. 10 to 0.60 ccm. 


" ferri dialys. .... 


TT[j tO XV 


0.05 to 1 ccm. 


" ferri nitrat. .... 


V\y to XV 


0.30 to 1 ccm. 


" pepsini ..... 


f 3 ij to iv 


8 to 16 ccm. 


" potassse ..... 


TT[v to XXX 


O.30 to 2 ccm. 


" potassii arsenit. (Fowler's solution) 


Til iij to vij 


0.20 to O.50 ccm. 


" potassii citrat. 


f 3 ij to iv 


8 to 16 ccm. 


" sodse ..... 


TT[v to xxx 


O.30 to 2 ccm. 


' ' sodii arseniatis (Pearson's solution) 


TT[iij to vij 


0.20 to 0.50 ccm. 


Lithii benzoas ..... 


gr. ij to v 


0.10 to 0.30 gm. 


" bromid. . . . . . 


gr. i to iij 


0.05 to 0.20 gm. 


" carb. ..... 


gr. ij to vi . 


0.10 to 0.40 gm. 


" citr 


gr. ij to v 


0.10 to 0.30 gm. 


" salicylas .... 


gr. ij to viij 


o.to to 0.50 gm. 


Lobelia ...... 


gr. v to x 


0.30 to 0.60 gm. 


Lupulinum ..... 


gr. v to x 


0.30 to 0.60 gm. 


Magnesia ..... 


gr. xv to Ix 


1 to 4 gm. 


Magnesii carb. .... 


gr. xv to lx 


1 to 4 gm. 


" citr. gran. 


3 j to viij 


4 to 32 gm. 


" sulphas .... 


3 j to viij 


4 to 32 gm. 


" sulphis .... 


gr. v to xxx 


0.30 to 2 gm. 


Manganesii oxid. nigr. (binoxid.) 


gr. ij to x 


0.10 to 0.60 gm. 


" sulphas .... 


gr. ij to x 


0. 10 to 0.60 gm. 


Manna ...... 


I i to ij 


30 to 60 gm. 


Massa copaiba? .... 


gr. v to xxx 


0.30 to 2 gm. 


*' ferri carb. .... 


gr. v to xv 


0.30 to 1 gm. 


" hydrarg. .... 


gr. i to xv 


0.05 to 1 gm. 


Mist ammoniaci . . . . 


f 3 iv to viij 


15 to 30 ccm. 


" asafoetidse .... 


f 3 iv to viij 


15 to 30 ccm. 


" chloroformi .... 


f 3 iv to viij 


15 to 30 ccm. 


" cretae ..... 


f 1 j to ij 


30 to 60 ccm. 


" ferri comp. . 


f § ss to ij 


15 to 60 ccm. 


" ferri et ammon. acet. 


f | ss to j 


15 to 30 ccm. 



DOSE TABLE. 



155 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Mist glycyrrh. com p. 




f 3 j to iv 


4 to 16 ccm. 


" magnes. et asafcet. 








f 3 j to iv 


4 to 16 ccm. 


" potassii citr„ 








f § ss to ij 


15 to 60 ccm. 


" rhei et sodae 








f | ss to j 


15 to 30 ccm. 


Morphiae murat. 








gr- i to | 


0.01 to 0.03 gm. 


' ' sulph. 








gr- ¥ to i 


0.008 to 0.03 gm. 


acetat. 








gr. i to $ 


0.01 to 0.03 gm. 


" sulph. liq. . 








f 3 j to iv 


4 to 16 ccm. 


" sulph. liq. (Mag< 


;ndie 






TTLij to XV 


0.10 to 1 ccm. 


Moschus . 








gr. v to x 


0.30 to 0.60 gm. 


Myrrha .... 








gr. x to xx 


0.60 to 1.20 gm. 


Napthalin 








gr. j to ij 


0.05 to 0.10 gm. 


Narceina . 








gr. £ to ij 


0.01 to 0.10 gm. 


Nicotia . 








gr- <ro to T V 


O.ooi to 0.025 gm, 


Nitro-glycerinum 








gr. <nr to A 


0.001 to 0.004 g m - 


Nux vomica 








gr. j to v 


0.05 to 0,30 gm. 


Oleoresina asphidii . 








gr xv to lx 


1 to 4 gm. 


" capsici . 








gr. 1 to £ 


0.01 to 0.03 gm. 


cubebae . 








gr. v to xxx 


O.30 to 2 gm. 


" lupulini . 








gr. ij to v 


0. 10 to 0.30 gm. 


piperis . 








gr. i to iij 


0.05 to 0.20 gm. 


zingiberis 








gr. j to iij 


0.05 to 0.20 gm. 


Oleum amygdal amar, 








mitoi 


0.008 to 0.015 ccm. 




' anisi 








TTLij to v 


0.10 to 0.30 ccm. 




' cajuput 








TTiij tO V 


0. 10 to 0.30 ccm. 




1 chenopodii . 








TTlV tO X 


0.30 to 0.60 ccm. 




1 copaibas 








TUviij to xv 


0.50 to 1 ccm. 




' cubebae 








TTLxv to xxx 


I to 2 ccm. 




' eriger . 








TliV tO XV 


0.30 to 1 ccm. 




1 eucalypti 








T^X tO XXX 


0.60 to 2 ccm. 




' limon. . 








TTLij to iv 


0.10 to 0.20 ccm. 




' morrhuae 








f 3 j to iv 


4 to 16 ccm. 




' olivae 








f 3 j to iv 


4 to 16 ccm. 




1 phosphoratum 








gr. j to iij 


0.05 to 0.20 gm. 




1 ricini 








f § j to iv 


4 to 32 ccm. 




* sabinae . 








TTLj to iij 


0.05 to 0.20 ccm. 




1 terebinth. 








TIL v to XXX 


0.30 to 2 ccm. 


" tiglii . 








n 1 to h 


0.01 to 0.08 ccm. 


Opium, 14 % morphine 








gr. 1 to il 


0.01 to 0.08 gm. 


Pa 


reira 








3 ss to j 


2 to 4 gm. 



1 5 6 



CLINICAL DIAGNOSIS. 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Paraldehyd, ..... 


TiLxx to xl 


1.20 to 2.40 ccm. 


Peiletierine 








gr. v to xv 


0.30 to I gm. 


Pepsin um purum 








gr. xv to § ss 


I to 15 gm. 


" saccharatum 








gr. xxx to § j 


2 to 30 gm. 


Petroleum 








3 ss to j 


2 to 4 gm. 


Phosphorus 








gr. T i F to & 


0.0005 to O.003 g m « 


Physostigminse salicyl 








gr. T i„ to ¥ L 


0.0005 to 0.003 g m . 


sulphas 








gr. T | ¥ to ¥ ^ 


0.0005 to 0.003 gm. 


Picrotoxinum . 








g r - eV lo £ 


0.001 to 0.02 gm. 


Pilocarpina and salts 








gr. eV to \ 


0.001 to 0.03 gm. 


Pil. aloes 








pil. j to iij 


pil. j to iv 


' ' aloes et asafoet. 








" ij to v 


" ij to v 


" aloes et ferri 








" j toiij 


" j to iij 


" aloes et mast. 








" j toiij 


11 j.tonj 


" aloes et myrrhse 








" ij to v 


" ij to v 


44 antim. comp. 








" i toii J 


4 j to iij 


'" asafoetidae . 








" j tovj 


" jtovj 


•* cathart. comp. . 








" j to iv 


" j to iv 


44 ferri comp. 








" ij to v 


" ij to v 


44 ferri iodidi 








" j to iv 


44 j to iv 


" galbani comp. . 








44 j to V 


44 j to V 


" hydrarg. 








gr. ss to xv 


0.025 to i gm. 


" opii . 








pil. j to ij 


pil. j to ij 


" phosphori . 








" j to iv 


44 j to iv 


" rhei . 








" ij to v 


" ij to v 


1 ' rhei comp. 








" ij to v 


44 ij to v 


Piperinum 








" gr. j to viij 


O.05 to 0.50 gm, 


Plumbi acetas . 








gr. \ to iij 


0.03 to 0.20 gm. 


" iodidum 








gr. \ to iij 


0.03 to O.20 gm. 


Potassii acetas . 








gr. xv to lx 


I to 4 gm. 


" bicarb. 








gr. v to lx 


0.30 to 4 gm. 


il bichromat. . 








gr- i to \ 


0.01 to 0.25 gm. 


bitartr. 








gr. j to ij. 


0.05 to O.40 gm. 


44 bromid. 








gr. v to lx 


0.30 to 4 gm. 


" carb. . 








gr. v to xxx 


0.30 to 2 gm. 


" chloras . , 






gr. v to xxx 


0.30 to 2 gm. 


" citras . . , 






gr. xv to lx 


I to 4 gm. 


" cyanid, . , 






gr. tV to \ 


0.004 to 0.008 gm. 


" et sodii tartr. , 






Si to j 


1 5 to 30 gm. 


" ferrocyanid. 








gr. x to xv 


0.60 to 1 gm. 



DOSE TABLE. 



157 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Potassii hypophosphis 


gr. v to xv 


O.30 to 1 gm. 


" iodid. . 






gr. ij to xv 


0.10 to 1 gm. 


44 nitras . 






gr. v to xv 


0.30 to 1 gm. 


" permanganat. 






gr. ss to j 


0.03 to 0.06 gm. 


41 sulphas 






3 j to iv 


4 to 16 gm. 


44 sulphidum . 






gr. j to x 


0.05 to 0.60 gm. 


44 sulphis 






gr. xv to xxx 


1 to 2 gm. 


44 sulphuret 






gr. ij to vj 


0. 10 to 0.40 gm. 


41 tartras 






3 j to viij 


4 to 30 gm. 


Prunus Virginia 






3 ss to j 


2 to 4 gm. 


Pulv. antimonialis . 






gr. iij to.x 


0.20 to 0.60 gm. 


44 aromat. . 






gr. v to xxx 


0.30 to 2 gm. 


44 cretee comp. 






gr. v to xxx 


0.30 to 2 gm. 


" glycyrrrh. comp. 






gr. xxx to lx 


2 to 4 gm. 


44 ipecac, et opii (Dover) 






gr. v to xv 


0.30 to 1 gm. 


44 jalapa comp. . 






gr. xxx to lx 


2 to 4 gm. 


44 morphinse comp. 






gr. v to xv 


0.30 to I gm. 


44 rhei comp. 






gr. xxx to lx 


2 to 4 gm. 


Quinidina (and salts) 






gr. j to xxx 


0.05 to 2 gm. 


Quinina (and salts) . 






gr. j to xxx 


0.05 to 2 gm. 


Quininse arsenias 






g r - i to j 


0.01 to 0.05 gm. 


Resina copaibse 






gr. ij to x 


0. 10 to 0.60 gm. 


44 jalapae 






gr. ij to v 


0.10 to 0.30 gm. 


44 podophylli . 






gr- i to i 


0.00S to 0.03 gm. 


44 scammonii . 






gr. ij to x 


0.10 to 0.60 gm. 


Resorcin .... 






gr. v to xxx 


0.30 to 2 gm. 


Rheum 








gr. ij to xxx 


0.10 to 2 gm. 


Sabina 








gr. v to x 


0.30 to 0.60 


Salicinum 








gr. v to xxx 


0.30 to 2 gm. 


Santoninum 








gr. j to v 


0.05 to 0.30 gm. 


Sapo 








gr. v to xxx 


0.30 to 2 gm. 


Scammonium 








gr. iij to xv 


0.20 to 1 gm. 


Scilla 








gr. i to ij 


0.05 to 0.10 gm. 


Senega 








gr. x to xx 


0.60 to 1.20 gm. 


Senna 








gr. v to lx 


0.30 to 4 gm. 


Serpentaria 








3 j to ij 


4 to 8 gm. 


Sinapis 








3 1 j 


8 gm. 


Sodii acetas 








gr. xv to lx 


I to 4 gm. 


4 ' arsenias 








g r - 6*1 to T(J 


0.001 to 0.005 g m « 


" benzoas 








gr. v to xv 


0.30 to 1 gm. 



i 5 8 



CLINICAL DIAGNOSIS. 



Remedies. 



Sodii bicarb. . 
" bisulphis 
" boras 
' ' bromid . 
" carb. 
" carb. exsicc. 
" chloras 
44 hypophosphis 
4 ' hyposulphis 
44 iodidum . 
' ' phosphas 
44 salicylas . 
44 santoninas 
44 sulphas 
44 sulphis 
Sparteine sulph. 
Spigelia . 
Spir. sether. comp. 
sether. nitrosi 
ammonite 
ammonige arom. 
camphorae 
chloroformi 
lavend. comp. 
menth. pip. 
Stramonii folium 
Strychnina and salts 
Styrax 
Sulphur . 

Syr. acidii hydriodidi allii 
calcii lactophos 
calcis 

ferri bromidi 
ferri iodidi 
ferri oxidi 
ferri hypophosph 
fer. quin. et str. phos 
hypophosphit. 
hypophosph. c. fer. 
ipecac. 



Dose expressed 

in terms of 

apothecaries' 

weights 
and measures 



gr. v to xxx 

gr. v to xxx 

gr. v to xxx 

g r - 

g r - 

g r - 

gr- 

gr. 

gr- 

gr. 



v to xxx 
v to xxx 
v to XV 
v to xxx 
v to XV 
v to xxx 
v to XV 
gr. ij to xv 
gr. v to xxx 
gr. ij to x 
gr. j to ij 
gr. v. to xxx 
gr- £ to £ 
gr. x to I j 

Til XXX tO lx 

f 3 ss to ij 

TTL V tO XXX 
TTL XV to xxx 

TT1 v tO XXX 
TT[ XV tO lx 
TTj, XXX tO lx 
TTl XXX tO lx 

gr. j to ij 

gr- 6T to tV 
gr. x to xx 
3 ss to iv 
f 3 j to iv 
f 3 j to ij 
nx, XV to XXX 
ttl xv to lx 

TI[ XV to lx 

i 3j 
f 3 j 
f3j 
f 3 j 

i 3 ss to iv 



Dose 
expressed in 
metric terms. 



0.30 to 2 gm. 
0.30 to 2 gm. 
0.30 to 2 gm. 
0.30 to 2 gm. 
0.30 to 2 gm. 
0.30 to 1 gm. 
0.30 to 2 gm. 
0.30 to 1 gm. 
0.30 to 2 gm. 
0.30 to 1 gm. 
o. 10 to 1 gm. 
0.30 to 2 gm. 
0.10 to 0.60 gm. 
0.05 to 0.10 gm. 
0.30 to 2 gm. 
0.01 to 0.03 gm. 
0.60 to 30 gm. 
2 to 4 ccm. 
2 to 8 ccm. 
0.30 to 2 ccm. 
1 to 2 ccm. 
0.30 to 2 ccm. 

1 to 4 ccm. 

2 to 4 ccm. 
2 to 4 ccm. 
0.05 to 0.10 gm. 
0.001 to 0.005 g m « 
0.60 to 1.20 gm. 

2 to 16 gm. 
4 to 16 ccm. 
4 to 8 ccm. 
1 to 2 ccm. 
1 to 4 ccm. 

1 to 4 ccm. 
4 ccm. 

4 ccm. 
4 ccm. 
4 ccm. 
4 ccm. 

2 to 16 ccm. 



DOSE TABLE. 



159 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Syr. kramerise .... 


f 3 ss to iv 


2 to 16 ccm. 




lactucarii 






f 3 j to iij 


4 to 12 ccm. 




pruni virginianas 






f 3 j to ij 


4 to 8 ccm. 




rhei 






f 3 j to iv 


4 to 16 ccm. 




rhei arom. 






f 3 j to iv 


4 to 16 ccm. 




rosse . . . 






f 3 j to ij 


4 to 8 ccm. 




rubi 






f 3 j to ij 


4 to 8 ccm. 




sarsap. comp. . 






f 3 j to iv 


4 to 16 ccm. 




scillse 






f 3 ss to j 


2 to 4 ccm. 




scillse comp. (hive-sirup) . 






Til XV to lx 


I to 4 ccm. 




senegse 






f 3 j to ij 


4 to 8 ccm. 




sennse 






f 3 j to iv 


4 to 16 ccm. 


Testa praeparata 






gr. v to xx 


0.30 to 1.20 gm. 


Thallin .... 






gr. iv to viij 


0.25 to 0.50 gm. 


Tinct. aconiti fol. 






TTLviij to xvj 


0.50 to 1 ccm. 




' aconiti rad. . 






TTtj tO V 


0.05 to 30 ccm. 




' aeon. rad. (Flemings) 






TTif tO ijSS 


0.04 to 0.15 ccm. 




1 aloes (1880) . 






f 3 ss to ij 


2 to 8 ccm. 




' aloes et myrrhae 






f 3 i to ij 


4 to 8 ccm. 




' arnicas nor. . . . 






TTlv to XXX 


0.30 to 2 ccm. 




' arnicae rad. . 






TTLxv to XXX 


I to 2 ccm. 




1 asafcetidae 






TT[xxx to lx 


2 to 4 ccm. 




1 belladonnas 






TT[v tO XV 


0.30 to 1 ccm. 




' calumbas 






f 3 i to iv 


4 to 16 ccm. 




' cannabis ind. 






Til xv to XXX 


1 to 2 ccm. 




' cantharid. 






TT[v tO XV 


0.30 to 1 ccm. 




' capsici . 






TTlv tO XV 


0.30 to 1 ccm. 




' cardamomi 






f 3 i 


4 ccm. 




' cardamomi comp. . 






f 3 1 


4 ccm. 




' catechu comp. 






f 3 ss to ij 


2 to 8 ccm. 




1 cimicifugas 






TTIXXX tO lx 


2 to 4 ccm. 




' cinchonas 






f 3 ss to ij 


2 to 8 ccm. 




' cinchonas comp. 






f 3 ss to ij 


2 to 8 ccm. 




' colchici rad. . 






TT[V tO XV 


O.30 to 1 ccm. 




' colchici sem. 






TTLv tO XV 


0.30 to 1 ccm. 




' conii 






TTlv to XXX 


O.30 to 2 ccm. 




' cubebas . 






f 3 j to ij 


4 to 8 ccm. 




1 digitalis 






TTlv tO XV 


9.30 to 1 ccm. 




1 ferri acet. 






TTlxv to XXX 


1 to 2 ccm. 




1 ferri chloridi 






TTlx to lx 


0.60 to 4 ccm. 



i6o 



CLINICAL DIAGNOSIS. 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Tinct. feni chloridi aether. 


TTLxv to XXX 


I to 2 ccm. 




' ferri pomati . 








TTLxv to lx 


I to 4 ccm. 




' gallse 








f 3 ss to ij 


2 to 8 ccm. 




gelsemii 








TT^V to XV 


0.30 to 1 ccm. 




' gentian comp. 








f 3 ss to 3 ij 


2 to 8 ccm. 




' guaiaci „ 








TT[XXX to lx 


2 to 4 ccm. 




' guaiaci ammon. 








TT[xxx to lx 


2 to 4 ccm. 




' hellebori 








Tt[x to XV 


0.30 to 1 ccm. 




' humuli . 








f 3 j to ij 


4 to 8 ccm. 




' hydrastis 








lUxxx to xc 


2 to 6 ccm. 




4 hyoscyami fol. 








TTLxv tO lx 


1 to 4 ccm. 




' hyoscyami sem. 








Ttlxv to XXX 


1 to 2 ccm. 




' ignatiae . 








TTl,V tO XV 


0.30 to 1 ccm. 




' iodini . 








TT[V tO X 


0.30 to O.60 ccm. 




' iodini comp. . 








TUij to x 


0.12 to 0.60 ccm. 




' ipecac, et opii 








TT[v tO XV 


0.30 to I ccm. 




' jalapae . 








f 3 ss to ij 


2 to 8 ccm. 




' kino 








f 3 ss to ij 


2 to 8 ccm. 




' krameriae 








f 3 ss to ij 


2 to 8 ccm. 




1 lavend. comp. 








f 3 ss to ij 


2 to 8 ccm. 




' lobelias . 








TiLxv to xlv 


1 to 3 ccm. 




' lupulini . 








f 3 ss to ij 


2 to 8 ccm. 




' matico . 








f 3 ss to ij 


2 to 8 ccm. 




' moschi . 








TT[XV to lx 


1 to 4 ccm. 




1 myrrhae 








f 3 ss to j 


2 to 4 ccm. 




' nuc. vomicae . 








TT|v tO xlv 


0.30 to 3 ccm. 




4 opii 








TTLv tO XV 


0.30 to 1 ccm. 




4 opii camph. . 








Tr[v tO lxXV 


0.30 to 5 ccm. 




4 phytolaccae 








TTLV tO lx 


0.30 to 4 ccm. 




4 physostigmatis 








TUV to XV 


0.30 to 1 ccm. 




4 quassiae 








f 3 ss to ij 


2 to 8 ccm. 




rhei 








f 3 j to viij 


4 to 30 ccm. 




4 rhei arom. 








TT|xxx to lxxv 


2 to 5 ccm. 




4 rhei dulc. 








f 3 j to iv 


4 to 16 ccm. 




4 sanguinariae . 








TTLXV tO lx 


1 to 4 ccm. 




4 scillae 








TTlVtO lx 


0.30 to 4 ccm. 




4 serpentariae . 








f 3 ss to ij 


2 to 8 ccm. 




4 stramon. fol. 








TTlv tO XV 


0.30 to 1 ccm. 




4 stramon. sem. 








TTlv to XV 


0.30 to 1 ccm. 




4 strophanthi . 








Tliij to vj 


0.10 to 0.40 ccm. 



DOSE TABLE. 



161 





Dose expressed 






in terms of 


Dose 


Remedies. 


apothecaries' 


expressed in 




weights 


metric terms. 




and measures. 




Tinct. sumbul. .... 


~V\y to xxx 


0.30 to 2 ccm. 


" valer. 








f 3 ss to ij 


2 to 8 ccm. 


" valer. ammon. 








f 3 ss to i j 


2 to 8 ccm. 


" veratr. vir. 








fliiij to x 


0.20 to 0.60 ccm. 


' ' zingiberis 








Tfyxv to lx 


1 to 4 ccm. 


Trinitrine (nitroglycerine) 








TTlj to iij 


0.05 to 0.20 ccm. 


Urethan . 








gr. xv tc lx 


1 to 4 gm. 


Uva ursi . 










3ss to j 


2 to 4 gm. 


Verat. alb. 


. 








gr. j to iij 


0.05 to 20 gm. 


Veratria . 


. 








ST- h to i 


0.005 to 0.02 gm. 


Zinci acet. 


. 








gr. j to ij 


0.05 to 0. 10 gm. 


*' bromid. 










gr. \ to ij 


0.03 to 0.10 gm. 


" cyanid. 










gr- A to \ 


0.055 to 0.015 gm. 


4 4 iodid. 


. 








gr. i to n j 


0.03 to 0.20 gm. 


" oxid. 


. 








gr. i to x 


0.05 to 0.60 gm. 


' ' phosphid 










gr. jV to \ 


0.005 to 0.01 gm. 


" sulphas (emetic) 








gr. xv to xxx 


I to 2 gm. 


" valerianas 






gr. j to v 


0.05 to 0.30 gm.] 



APPENDIX. 



To End of Chapter I., Page 7. 

In malaria, and less frequently in scarlatina, there are seen in the 
red blood corpuscles amoeboid bodies (plasmodia), which sometimes 
contain granules of black pigment. 



To End of Chapter III., Page 31. 

SYMPTOMS OF THE MOST IMPORTANT DISEASES OF THE LUNGS. 

I. — Pneumonia : Dulness over the infiltrated portion of the lung ; 
this is not absolute and often slightly tympanitic. Auscultation in the 
stage of engorgement gives crepitant rales, in the stage of hepatization 
bronchial breathing, and in the stage of resolution crepitant rales 
again. The pectoral fremitus is increased. 

II. — Pleurisy : With the presence of a pleuritic effusion the 
affected side is enlarged and moves less than the corresponding side ; 
in the neighborhood of the effusion there is absolute dulness, and a 
weakening of the respiratory murmur and of the pectoral fremitus. 
Above the effusion of fluid, there is often heard a tympanitic sound 
of the compressed lung with Wintrich's change of note, bronchial 
breathing, and segophony. As for the upper border of the pleuritic 
exudation and its movement see page 24. In large effusions the 
neighboring organs are pressed aside (heart, liver, spleen). If a 
pleurisy heals with adhesion of both pleural surfaces and contraction 
of the newly formed connective tissue, there is a retraction of the 
corresponding chest wall, and a drawing in of the neighboring organs 
around it. Dry pleurisy is characterized by a friction sound. 

163 



164 CLINICAL DIAGNOSIS. 

III. — Emphysema : Barrel-shaped enlargement of the chest. The 
lower border of the lungs is deeper ; diminution in the size of the 
cardiac dulness ; weakening of the respiratory murmur ; often dry- 
rales. 

IV. — Pneumothorax : Enlargement and immobility of the affected 
half of the chest, a percussion note abnormally loud and deep, rarely 
tympanitic, and which extends over the normal borders of the lungs. 
Neighboring organs pressed aside. On striking the chest with the 
percussion hammer, and auscultating at the same time, a metallic 
sound is heard. Weakened, often amphoric breathing, weakened 
vocal fremitus. When fluid is also present there is a momentary 
change in the level of the fluid on sitting up and lying down. 
Succussio Hippocratis. 

To Page 39, Line 4. 

THE LARYNGOSCOPY EXAMINATION. 

The patient is requested to take hold of the tongue with a towel 
held between the thumb and index finger and draw it forward with 
open mouth. A bright light is then reflected into the throat by the 
head mirror, while the laryngoscopic mirror, slightly warmed over 
the lamp, is introduced and pressed gently against the uvula. By 
making the patient say "a" or " e" the epiglottis is raised up and 
the anterior (upper in the mirror) part of the laryngeal contents are 
seen. If it is desired to see the trachea as far as the bifurcation, the 
patient is made to sit high, with the head bent somewhat forward 
and the mirror held more horizontally. 

In the laryngoscopic mirror there is then seen above (forward), the 
epiglottis; from here the ary-epiglottic folds running below (backward) 
to the arytenoid cartilages, whose situation is shown by the cartilages of 
Santorini visible as a slight prominence ; somewhat further outward 
from these are the cartilages of Wrisberg. Between the two ary- 
epiglottic cartilages is found the inter-arytenoid region. At the vocal 
cords we distinguish an anterior ligamentous portion which reaches to 
the top of the processus vocalis of the arytenoid cartilage, and a 
posterior part situated between the top and the base of the processus 
vocalis. Correspondingly we distinguish also at the vocal chink an 
anterior portion (glottis phonatoria) and a posterior portion (glottis 
respiratoria). Above the vocal cords and parallel with them are seen 
the false cords. 



APPENDIX. 165 

To End of Chapter V., Page 40. 

In organic paralyses, as in those caused by a lesion of the recurrent 
laryngeal nerve, the abductors are generally most early and most 
frequently affected. In neuroses, as in hysteria, for example, there 
is generally, on the contrary, a paralysis of the adductors (aphonia 
from insufficient closure of the glottis). In laryngitis there is often a 
disturbance of function of the thyro-arytenoid muscle. 

RHINOSCOPY. 

The examination of the nose may be made anteriorly by means of 
a nasal speculum (rhinoscopia anterior) and posteriorly through the 
pharynx (rhinoscopia posterior). In rhinoscopia anterior the septum 
is seen on the median side, and on the external part, the lower, middle, 
and occasionally also the upper turbinated bone. Between the floor 
of the nasal cavity and the lower turbinated bone is the lower nasal 
passage, between the lower and middle, the middle nasal passage, and 
between the middle and upper, the upper nasal passage. The space 
situated between the middle turbinated bone and septum contains the 
pars olfactoria, while that between the floor of the nasal cavity and 
the free border of the middle turbinated bone contains the pars 
respiratoria. The mucous membrane of the latter part contains 
pavement epithelium as far as the cartilaginous part of the nose is 
concerned ; the rest of the nasal mucous membrane consists of 
cylindrical ciliated epithelium. 

To examine the posterior nares a small mirror like the laryngeal 
mirror is used with surface almost at right angles to the handle. The 
tongue is held down with a spatula, and the mirror is passed behind 
the uvula and relaxed soft palate. First the posterior border of the 
septum, then the turbinated bones are looked for, and then by turn- 
ing the mirror to the side the projection of the Eustachian tube, 
Rosenmuller's groove, and by raising the handle, the roof of the 
posterior nasal region is seen. Here the pharyngeal tonsil is seen. 
Near the lower border is found a round opening which leads to the 
bursa pharyngea. 

The nose serves for the sense of smell and for respiration, for the 
latter by warming the passing air and saturating it with vapor. For 
the innervation of the nasal cavity and the testing of the sense of 
smell, see Chapter XII. 



1 66 CLINICAL DIAGNOSIS. 

To End of Chapter VII., Page 54. 

SYMPTOMS OF THE MOST IMPORTANT DISEASES OF THE HEART. 

I. — Pericarditis : Increase of the cardiac dulness in a triangular 
form, especially upward. Apex beat weak, situated low and more 
upward than normal, often further inward than the left border of the 
heart dulness. Heart sounds indistinct. Pericardial friction. 

II. — Aortic Stenosis : Apex beat situated a little more outward 
and lower than normal, rarely strengthened. Heart dulness a little 
enlarged to the left. A very loud systolic murmur audible over all 
areas, but loudest at the aorta and is transmitted along the carotid. 
The first mitral and second aortic sound not audible. Pulse small, 
hard, slow and less frequent. 

III. — Aortic Insufficiency : Apex beat very much strengthened 
and situated more to the left, and lower than normal. Heart dulness 
extends above and to the left. A diastolic gushing murmur over the 
aorta, often also over the sternum and the third left rib, frequently an 
accidental systolic mitral murmur and accentuation of the second 
pulmonary sound. Pulse large, quickened. Murmurs heard at the 
cruralis and cubitalis. Capillary pulse. 

IV. — Mitral Stenosis : Apex beat more to the left. Heart dulness 
increased to the right. Epigastric pulse, diastolic (presystolic) 
murmur and a wheezing sound at the apex, strengthened first mitral 
sound, accentuation and splitting of the second pulmonary sound. 
Pulse small, soft, and irregular. 

V. — Mitral Insufficiency: Apex beat and heart dulness as in 
mitral stenosis. Systolic murmur heard over the mitral area, often 
also over the pulmonary area. Accentuation of the second pulmonary 
sound. Pulse about the normal size, but is small and irregular when 
compensation has not taken place. 

VI. — Insufficiency of the Tricuspid occurs generally with mitral 
affections. Heart dulness increased on the right side, systolic 
murmur at the tricuspid, weakening of the second pulmonary sound. 
Venous pulsation in the neck and liver. 

VII. — Stenosis of the Pulmonary Artery : Very rare, generally 
congenital and combined with other heart anomalies, much cyanosis, 
hypertrophy of the right ventricle, systolic murmur over the pulmonary 
area, second pulmonary sound weak. Pulse small. Disposition to 
pulmonary tuberculosis. 



APPENDIX. 167 

VIII. — Insufficiency of the Pulmonary Artery : Very rare. Large 
area of heart dulness on the right side, diastolic and generally also a 
systolic murmur over the pulmonary area. Pulse small. 

IX. — Aneurism of the Aorta : Pulsating tumor in the region of 
the second and third rib on the left side. Dulness and systolic 
occasionally, also a diastolic murmur in the same region. Hyper- 
trophy of the heart begins when there is an insufficiency of the aortic 
valves. Inequality of the radial pulse on each side. 

After Line 23, Page 78. 

Dr. D.. Meredith Reese, of the Johns Hopkins Hospital, Baltimore, 
has found trichloracetic acid a very delicate and trustworthy reagent 
in testing for albumen. It may be used in crystals which are dropped 
in the urine to be tested, or in a liquid form in a saturated solution, 
or in one of medium strength. 

After Line 17, Page 85. 

VI. — Pubner's Test. To the urine in a test tube a saturated 
solution of the acetate of lead in excess is added. This is filtered, 
and to the filtrate as much ammonia is added to cause a permanent 
precipitate, and then the whole is heated, but not to the boiling point. 
If sugar is present, it becomes a beautiful red color. 

After Line 10, Page 89. 

Aniifebrin. The urine is heated to boiling in a test tube for a few 
minutes with one-fourth its volume of concentrated muriatic acid, 
cooled off, and to it are added a few drops of a three-per-cent. carbolic- 
acid solution and one drop of a diluted chromic-acid solution. A red 
color appears, which turns to a rich blue on making the solution 
alkaline with ammonia. 

After Line 10, Page 89. 

Phenacetin. To the urine in a test tube about two drops of 
muriatic acid and the same quantity of a one-per-cent. sodium nitrite 
solution are added, and on this are poured a few drops of an alkaline 
watery solution of naphthol to make it alkaline, when a bright red 
color appears. If carbolic acid is taken instead of naphthol, an 
orange-yellow color appears in an alkaline solution, and a red color in 



1 68 CLINICAL DIAGNOSIS. 

an acid solution. These colors are best recognized by pouring the 
mixture on filter paper. With oxidizing substances, as chloride of 
iron, chloride of calcium, etc., the phenacetin is colored a brownish 
red. 

After Line 12, Page 102. 

The oidium albicans, or thrush fungus, represents the transition 
member from the hyphomycetes or moulds to the blastomycetes or 
yeasts. It is found in the mouth, more rarely in the oesophagus and 
stomach in the form of white spots or patches, which on microscopical 
examination are seen to be a tangled mass of abundantly branching 
filaments with shining round or oval spores (conidia) at the points of 
bifurcation. 

After Line 23, Page 102. 

Blastomycetes, or yeast fungi, consist of oval, shining cells, which 
increase by the shooting forth of a daughter cell in the form of a bud- 
like protrusion from the mother cell (gemmation). Yeast fungi are 
the cause of the fermentation of grape sugar into alcohol and carbonic 
acid ; they are occasionally found in fermenting contents of the 
stomach. 

After Line 25, Page 102. 

The Schizomycetes, or bacteria, are the lowest organisms known. 
They increase by the mother cell dividing by fusion into two or more 
daughter cells. Besides this increase by simple division or fission, 
certain bacteria, as the anthrax bacilli, increase by spore formation. 
The spores consist of "resting forms," since they offer a much 
greater resistance to external influences, as of heat, drying, the effect 
of antiseptics, than the " growing forms," and consequently are ranked 
with the most hardy and least easily destroyed organisms. All germs, 
when exposed to a dry heat at 140 C. (284 F.) for three hours, or 
to steaming vapor at ioo° C. (212° F.) for a quarter to a half an hour, 
are with certainty destroyed. Also a sure destruction of all germs — 
that is, a sterilization, may be procured by a corrosive-sublimate 
solution I to 1,000, 1 or ftve-per-cent. carbolic-acid solution. The 
" growing forms " of bacteria are destroyed at a temperature of 50 
to 6o° C. (120 to 140 F.). 

1 TThis is doubtful.] 



APPENDIX. 169 

Micro-organisms are developed in part on dead substances of 
organic origin, such as on animal or vegetable bodies, on the ground 
or water. These are called Saprophytes in opposition to the parasitic 
organisms which only flourish in the living bodies of higher organ- 
isms. 

Many kinds, as the anthrax bacilli, can subsist on dead soil as well 
as on animal bodies ; facultative parasites. To this class belong the 
organisms of the infectious diseases, which are also called pathogenic 
organisms. 

Many micro-organisms cause certain chemical changes in their 
culture media, thus putrefaction and fermentation (acetic-acid fer- 
mentation of alcohol, lactic-acid fermentation of glucose) are due to 
the working of bacteria. Some kinds liquefy the gelatine and other 
culture media by peptonizing it ; other bacteria produce gas or 
pigment. 

The putrefactive and pathogenic micro-organisms especially pos- 
sess the property of forming certain basic products of metabolism 
which are called ptomaines. Many of these ptomaines show them- 
selves in violent poisons, as toxines. The effect of the pathogenic 
bacteria is to be explained chiefly by saying that they engender such 
extremely poisonous substances which do great harm to the organism 
and thus cause the different diseases. 

Among the ptomaines which are formed with the putrefaction of 
animal substances may be mentioned the simple organic ammonias 
(methylamine, dimethylamine, trimethylamine, ethylamine), also the 
more complex bases as choline, neurine, muscarine, betaine, cadaver- 
ine, or penta-methylendiamine, putrescine, etc. 

Of the pathogenic bacteria, the typhoid bacilli cause a poisonous 
ptomaine, typhotoxine ; the tetanus bacilli, tetanine, tetano-toxine, 
spasmo-toxine ; the cholera bacilli, two putrefactive ptomaines, two 
specific toxines. Also the pus-exciting cocci seem to produce poison- 
ous substances. 

To Chapter XL, Page 107. 

A LIST OF THE MOST IMPORTANT PATHOLOGICAL MICRO-ORGANISMS. 

Bacillus Anthracis, Bacillus of Malignant Postule or of Splenic 
Fever (Plate, Fig. 3). These bacilli are large thick rods with sharply 
truncated ends, often, indeed, so concave that between the ends of 



170 CLINICAL DIAGNOSIS. 

two rods an oval aperture is seen. They are in the tissue juice of the 
malignant pustule, and especially in the blood. They grow at the 
temperature of the room on gelatine by liquefying it, and they grow 
also on most of the other media. They form spores under certain 
circumstances, but not in the living body. These bacilli may be 
stained with all the basic aniline colors. Mice are especially sus- 
ceptible to this poison, and die in from 24 to 36 hours after the 
inoculation, and in the blood of the inoculated animal an enormous 
number of bacilli are found. Guinea-pigs, rabbits, sheep, and oxen 
are also susceptible. 

Bacillus GEdematis Maligni, Bacillus of Malignant CEdema, or 
Bacillus of Progressive Gangrene. These bacilli are more slender 
than the anthrax bacilli and have rounded ends. They are strictly 
anaerobic, that is, they grow only by the exclusion of oxygen ; they 
may be stained with the aniline colors, and cause in some cedema and 
emphysema of the skin. In the cedematous fluid the bacilli are 
found. 

Bacillus Tuberculosis (Plate, Fig. 7). These bacilli are slender 
rods about 5 }i long. They grow only at the temperature of the 
body on blood serum [and potatoes], and their development is very 
slow. They are stained according to the methods above given. 
Wherever this bacillus is found there is a question of tuberculosis. 
It is found in the sputum in pulmonary tuberculosis ; in the fasces and 
urine in tuberculosis of the intestinal and genito-urinary tract ; in pus 
in tuberculous suppuration of the bones and glands ; in the blood in 
miliary tuberculosis ; and in the skin in lupus. Guinea-pigs, rabbits, 
cattle, and other animals are susceptible to tuberculosis. 

Bacillus Leprce (Plate, Fig. 8). These are smaller than the tubercle 
bacilli, but otherwise resemble them closely. It has not been possible 
to cultivate them outside of the human body. They are stained like 
the tubercle bacilli by Ehrlich's method, and also with the aniline 
colors. They are found in all leprous neoplasms and also in the 
tissue juice in large numbers, particularly in the cells. 

Bacillus Mallei, or Bacillus of Glanders (Plate, Fig. 9). These are 
like the tubercle bacilli, only somewhat thicker. They grow at the 
temperature of the body on agar-agar and blood serum as well as on 
potatoes, and are stained with all the aniline colors, but the best is 
with Loffler's methylene blue. They are found only in blood and in 
the fresh nodules of glanders, not in the decomposing and ulcerating 



APPENDIX. I/I 

ones. Therefore a microscopic examination of the pus and secretions 
is of less value than inoculation on small animals, as field mice and 
guinea-pigs. 

Bacillus Cholera, or Cholera Bacillus (Plate, Fig. 2). These are 
short, curved rods called comma bacilli, which often grow out to 
spirilla or screw-shaped threads. They grow at the temperature of 
the room on gelatine by liquefying it in a characteristic, funnel- 
shaped cone. The culture also lives in other media, and even in 
water. If sulphuric acid be poured upon the gelatine culture it 
strikes a purplish red color. The cholera bacilli are best stained with 
a concentrated watery fuchsin solution. They are found in the stools 
of those sick with cholera. Their presence must be proved by culture, 
as there are other bacilli in the stools that resemble them, — for 
example, the bacilli of Finkler-Prior, which plainly behave very 
differently in the culture medium, — for example, they liquefy the 
gelatine more quickly, and in the shape of a stocking. 

Bacillus Typhostis, or Bacillis of Typhoid Fever (Plate, Fig. n). 
These are short rods with rounded ends and are about as long as a 
red blood corpuscle. They grow at the temperature of the room on 
gelatine without liquefying it, and also on agar-agar, blood serum, and 
potatoes. The potato culture, which gives an extensive filmy growth 
almost invisible to the eye, is especially characteristic for the typhoid 
bacillus. These bacilli also thrive in milk and in water. They do 
not stain well with the ordinary aniline colors, but Lofner's methylene 
blue and Ziehl's carbolic acid fuchsin color them well. They are 
found in most cases of typhoid fever in the intestines, spleen, and 
blood. They are passed out with the feces, but as so many bacilli 
like them are found in the stools, their presence can not be detected 
by staining or a microscopical examination, but only by cultures. 

Spirillum Obcrmeieri, or Spirillum of Relapsing Fever (Plate, Fig. 
4). These are slender, actively moving, spiral-formed bacteria, which 
are found in the blood in relapsing fever, but only during an attack. 
They may be seen by high power in the unstained blood drop (see 
page 7) or cover-glass preparation of the blood, and are quickly 
stained with a watery solution of fuchsin or other aniline colors. 
Attempts to cultivate them outside of the body have not yet been 
successful. 

Pneumonococcus, or Bacillus of Pneumonia (Plate, Fig. 1). Fried- 
lander demonstrated in the lungs and sputum of croupous pneumonia 



\J2 CLINICAL DIAGNOSIS. 

an oval coccus which was distinguished by a thick capsule. This 
grows at the temperature of the room on gelatine and other media 
without liquefying them. A. Frankel obtained from pneumonic lungs 
pure cultures of another coccus which generally appears in the form 
of a diplococcus and is lanceolate. It is likewise in the body sur- 
rounded by a capsule in culture. It grows only at body temperature 
(24°-42° C. [75 to 106 F.]) on gelatine, agar-agar, blood serum, 
and bouillon. The cultures have a short life and easily lose their 
virulence. Frankel's diplococcus is very virulent for rabbits, guinea- 
pigs, [?] and mice, and is found in the blood of infected animals. It 
is stained with all aniline colors. The best test is the inoculation of 
those animals which die regularly in 24 to 48 hours. This same 
coccus is also found in the normal sputum (micrococcus of sputum 
septicaemia) ; it is also found in empyema and cerebro-spinal menin- 
gitis following pneumonia. 

Bacillus Diphtherilicus of Lojfler, or Bacillus of Diphtheria. 
These are thick curved bacilli about the length of the tubercle 
bacilli. They are found in the diphtheritic false membrane, but it is 
a question whether they are constantly present in the disease. They 
grow on gelatine and other culture media at the temperature of the 
body. They may be stained with Loffier's methylene blue. The 
examination of diphtheria bacilli has reached no diagnostic import- 
ance. 

Streptococcus Erysipelatos, or Micrococcus of Erysipelas (Plate, Fig. 
6). These are small round cocci which tend to form themselves into 
long chains (streptococci). They are found in every case of erysipelas 
in the most freshly diseased portion of the skin, during suppuration 
following erysipelas, but are not generally found in the serous 
contents of the erysipelas bullae of the skin. They grow at the 
surrounding temperature on gelatine and many other culture media 
without liquefying them. They may be stained with all aniline colors 
and according to Gram. They are not pathogenic for rabbits. 

Gonococczis, or Micrococcus of Gonorrhoea (Plate, Fig. 10). These 
are large cocci, generally in the form of diplococci which are flattened 
at the point of contact. They are often found in large groups within 
leucocytes, filling the entire protoplasm and leaving only the nucleus 
free. They are cultivated with great difficulty on blood-serum. 
They are stained in dried preparations with all the aniline colors, but 
better with a concentrated watery solution of methylene blue. They 



APPENDIX. 173 

are constantly found in gonorrhceal pus, and their presence is of 
diagnostic importance. 

Staphylococcia Pyogenes Aureus, (Plate, Fig. 5). These are small 
round cocci which are arranged in masses. They thrive at the 
surrounding temperature on gelatine and liquefy it, and also grow on 
other media, and with their growth a golden yellow color is formed. 
They are stained with all the aniline colors, and according to Gram. 
These are the most frequently present of the pus-producing cocci. 
They are found in abscesses, phlegmon, in purulent inflammation of 
the joints and serous surfaces, and are extensively present in pyaemia. 
They are found in certain forms of endocarditis of the valves, and in 
the marrow of osteomyelitis. Finally, they are not unusually found 
as a mixed infection with other infectious diseases, as in the 
suppuration from typhoid fever, or in the contents of a variola 
pustule. 

Streptococcus Pyogenes. These are much like the erysipelas cocci in 
so many ways that many consider the two kinds identical. They are 
found in suppuration and in many forms of puerperal fever, also in 
endocarditis. The diseases caused by these streptococci often run an 
especially severe and malignant course. Besides these above-named 
cocci of suppuration, others are at times found in pus, as the Staphy- 
lococcus Pyogenes Aldus, Staphylococcus Pyogenes Ciireus, and others. 
Also in typhoid malaria, rhinoscleroma, carcinoma, yellow fever, and 
many other diseases, micro-organisms have been found and described, 
but they need further confirmation. 



INDEX. 



Abbe s condenser, 105 

Abdomen, 62 

Acarus folliculorum, 101 

" seabiei, 100 
Acetone, 85 

test for, 85 
Achorion Schoenleinii, 101 
Acid, amido-caproic, 87 
" amid o-hydroparacumario, 

87 
aromatic oxi-, 73 
carbolic, 73 
carbonic, 75 
chrysophanic, 89 
diacetic, 86 
hippuric, 73 
hydrochloric, 74 
muriatic, 74 
oxalic, 73 
phosphoric, 75 
sulphuric, 75 

test for, 75 
uric, 71 
" test for, 73 
Actinomycosis, examination of, 
107 
" in sputum, 36 

j^Egophony, 30 
Air, complemental, 21 
" ordinary breathing, 21 
" reserve, 21 
" residual, 21 
Albumen, 77 

acetic acid and ferro- 
cyanide of potassium, 
test for, 78 
amount used, 136 
" set free, 136 



Albumen, biuret test for, 78 
heat test for, 77 
Heller's test for, 77 
picric acid test for, 78 

Ammonia, 76 

test for, 132 

Amoeba coli, 101 

Anaemia, progressive perni- 
cious, 7 
" secondary, 6 

Ancesthesia, 108 

Analgesia, no 

Anasarca, 92 

Anguillula intestinalis, 99 

Angulus Ludovici, 16 

Aniline colors, 104 

Ankylostomum duodenale, 99 

Anode, 115 

Apnoea, 20 

Arthropodes, 100 

Ascaris lumbricoides, 98 

Ascites, 92 

Aspergillus glaucus, 102 
niger, 102 
threads in sputum, 36 

Ataxia, 112 

Auscultation, 27 

Balantidium or paramgecium coli, 

10 r 
Bacillus anthracis in sputum, 36 
Bacillus or rod, 102 
Bacteria, 102 
Biermer, 26 
Bile, 80 

" coloring matter of, 80 
Bilirubin, 80 

" Gmelin's test for, 80 



175 



iy6 



CLINICAL DIAGNOSIS. 



Biliverdin, 80 

Biuret reaction, 70 

Bizzozero, 3 

Bladder, 67 

Blood, amount of haemoglobin 
in, I 
" bacilli anthracis in, 7 

" leprae in, 7 
" examination of the, 4 
' ' micro-organisms in, 7 
" quantity of, I 
" reaction of, 1 
" specific gravity of, I 
" spirilla of recurrent fever 

in ' 7 
" tubercle bacilli in, 7 

" in urine, 79 
Blood corpuscles, dwarf, 2 

" enumeration of , 5 
" giant, 2 

" proportion between 
red and white, 5 
Blood-plaques, 3 
Blood-vessels, auscultation of, 48 
Bothriocephalus latus, 97 
Bouchut, 5 

Brain and spinal cord, 124 
Breast, chicken, 16 
" cobbler's, 16 
" funnel, 16 
Breathing sound, 27 

" amphoric, 27, 28 
" bronchial, 27, 28 
" changes in the fre- 
quency of, 20 
" increase in the fre- 
quency of, 20 
" undetermined, 27, 28 
" vesicular, 27 
Bronchophony, 29 
Bruit de pot fele, 21 
Burdach, 123 

Calcium, 76 

" sulphate of, 76 
Calculi, faecal, 134 

" salivary, 134 
Casts in urine, 90 
Centre for arm, 124 



Centre for face, 124 
leg, 124 

sense of sight, 124 
" speech, 124 

Cercomonas intestinalis, 101 
Cestodes, 96 
Charcot, 36, 65 
Chest, circumference of, 18 
" enlargement of, 18 
" topography of, 16 
Cheyne, 20 

Cheyne-Stokes respiration, 20 
Chicken-pox, 12 
Chlorosis, 7 
Choletelin, 80 
Choreic movements, 113 
Clavicle, 16 
Clonus, foot, 122 

" patellar, 122 
Coccus, 102 

Coefficient of Haser, 68 
Concrements, analysis of the 
pathological, 132 
urinary, 132 
Condenser, Abbe's, 105 
Convulsions, 1 12 
Creatinine, 73 
Cressol, 73 
Crisis, 9 

Crystals, Charcot-Leyden, in 
sputum, 36 
" cholesterine, in spu- 
tum, 36 
' ' fatty acid, in sputum, 35 
" leucine, in sputum, 36 
" tyrosine, in sputum, 36 

Current, constant, 113 
" density of, 113 
" faradic, 113 
" galvanic, 113 
" intensity of, 113 
" interrupted, 113 
" strength of, 113 
Curschmann, 35 
Cypho-scoliosis, 16 
Cyphosis, 16 
Cysticercus cellulosae, 97 
Cystin, 133 

" test for, 133 



INDEX. 



177 



Dextrose, 81 

" bismuth test for, 84 
" Bottger's test for, 84 
" Fehling's test for, 83 
" fermentation test for, 

81 
" Moore's test for, 82 
Mulder's test for, 84 
" phenylhydrazin test 

for, 84 
" polarization test for,S5 
" quantitative test for, 83 
" reduction tests for, 82 
" Trommer's test for, 82 
Diacetic acid, 86 

" test for, 86 
Diagnosis, by means of electrici- 
ty, 113 
Diazoreaction, 86 
Diet of sustenance, 136 
Distomum haematobium, 100 
hepaticum, 100 
lanceolatum, 100 
Dose table, 144 
Dubrisay, 5 

Ductus arteriosus Botalli, 44 
Dulness, cardiac, 43 
Duperie, 5 
Dyspnoea, 19 

expiratory, 19 
inspiratory, 19 
" mixed form of, 20 

Ehrlich, 3, 4, 105 
Electrodes, 113 

Elementary granular masses, 3 
Eosinophile cells, 4 
Epithelium, alveolar, in sputum, 

34 
cylindrical, in spu- 
tum, 34 
pavement, in spu- 
tum, 34 
in sputum, 89-90 
Erysipelas, 15 
Ewald, 57 
Exner, 39 

Fastigium, 9 
Fat 87 



Favus fungus, 101 
Faeces, 63 

" in cholera, 65 

" color of, 64 

" consistence of, 63 

" crystals in, 65 

" of Charcot-Neu- 
mann in, 65 

" digestive juices in, 63 

" in dysentery, 65 

" epithelium in, 66 

" fat in, 65 

" leucocytes in, 65 

" micro-organisms. 66 

" mucus in, 64 

" products of excretion in, 
63 

" red-blood corpuscles in, 

" remains of food in, 63, 65 

" in typhoid fever, 65 
Febris continua, 9 

" intermittens 9, 14 

" recurrens, 13 

" remittens, 9 
Fermentation tubes, 82 
Fever, considerable, 8 

" high, 8 

" intermittent, 14 

" malarial, 14 

" moderate, 8 

" relapsing, 13 

" scarlet, IO 

" slight, 8 

" typhoid, 12 

" typhus, 13 
Filaria medinensis, ico 

" sanguinis, 99 
Fluid, battery, 115 

" diluting, 5 
Flea, 101 
Food, absorption of, 142 

" composition of, 142 
Formula of Reuss, 92 
Fremitus, pectoral, 31 
" vocal, 31 
" pericardial, 42 

pleuritic, 30 
" Friedlander, 107 



i;8 



CLINICAL DIAGNOSIS. 



Gallic acid, Pettenkoffer's test 

for, 81 
Gall-stones, 134 

Gastric juice, amount of acid in, 
53 
" digesting strength 
of, 59 
Gerhardt, 26 
Gibbus, 16 
Gmelin, 64 

Gonococci, staining of, 107 
Gram, 2, 106 
Grape sugar, 81 

" " bismuth, test for, 84 
" " Bottger's test for, 

84 
" " Fehling's test for, 

83 
" " fermentation test 

for, 8r 
" " Moore's test for, 

82 
" " Mulder's test for, 

84 
" " phenylhydrazin test 

for, 84 
" " polarization test 

for, 85 
" ' " quantitative test 

for, 83 
" " reduction tests for, 

82 
" " Trommer's test for, 

82 
Gypsum, 76 

Haematin, I 
Haematoblasts, 3 
Haematoidin in sputum, 35 
Haematuria, 79 
Haemin, I 
Haemoglobin, I 
Hsemoglobinuria, 79 
Haser, coefficient of, 68 
Halla, 5 
Harrison, 17 
Harrison" furrow, 17 
Hayem, 3, 5 
Heart, apex beat of the, 41 



Heart, auscultation of the, 45 
" inspection and palpation 
of, 41 
Heart, movements of the, 42 
" percussion of the, 43 
" sounds of the, 45 
Heart murmurs, 46 

" diastolic, 46 
" endocardial, 47 
" pericardial, 47 
" friction, 

47 
" presystolic, 46 
" strength of, 46 
" systolic, 47 
Heart sounds, metallic 46 

" reduplication of 

the, 46 
' ' reduplication of 
the first, 46 
Hemialbumose, 78 

" test for, 78 

Hemianopsia, 124 
Hemiplegia, in 
Herpes circinatus, 101 
" tonsurans, 101 
Hippocrates, 30 
Hoffmann, 141 
Human body, table of the weight 

and height of, 143 
Hydrobilirubin, 80 

test for, 81 
Hydrocele, 92 
Hydrocephalus, 92 
Hydronephrosis, 94 
Hydro-quinone, 73 
Hydrothorax, 92 
Hyperaesthesia, 108 
Hyperpyrexia, 9 
Hyphomycetes, 101 
Hypochrondrium, 17 
Hypoxanthine, 73 

Indican, 73 

" test for, 74 
Inspiration, duration of expira- 
tion and, 19 
Iron, 77 
Itch-insect, 100 



INDEX 



179 



Kidneys, 67 
Koch, 106 
Konig, 141 
Kronecker, 57 

Laache, 5 

Lactose, 85 

Laryngoscopy, 37 

Larynx, 37 

" auscultation of the, 37 
" muscles of the, 38 
" nerves of the, 38 
" percussion of the, 37 

Law, Ohm's, 116 

Leptothrix forms, 103 

threads in sputum, 36 

Leube, 58 

Leucaemia, 6 

" lymphatic, 6 

Leucine, 87 

Leuckart 99 

Leucocytes, 3 

pigment containing, 

7 
in sputum, 34 
in urine, 89 

Leucocytosis, 6 

Leyden, 36 

Line, anterior axillary, 17 
" costo-articular, 17 
" mammary, 17 
" median, 17 
" middle axillary, 17 
" parasternal, 17 
" posterior axillary, 17 
" scapula, 17 

Liver, 60 

" position of, 60 

Lordosis, 16 

Louse, body, 101 
" crab, 101 
" head, 101 

Lung, apex of the, 21 
" dulness over the, 23 
" lower border of, 22 
" movement of the, 22 
" normal boundaries of, 21 
" topography of the lobes 
of the, 22 



Lung, total capacity of, 20 

" upper boundary of, 21 
Lymphocytes, 3 
Lysis, 9 

Magnesium, 76 

Malaria, 14 

Malassez, 5 

Measles, 10 

Meinert, 137 

Melanine, 87 

test for, 87 

Meltzer, 57 

Metabolism and nutrition, 136 

Microcytes, 2 

Micro-organisms, 7 

coloring of, 104 
Gram's method 
of staining, 
106 
in sputum, 36 
" urine, 91 

Microsporon furfur, 101 

minutissimum, 102 

Mohrenheim, 16 

Mohrenheim's groove, 16 

Moleschott, 5 

Monoplegia, 11 1 

Morbilli, 10 

Motility, testing the, in 

Motor symptoms of irritation, 
112 

Muller, F., 141 

Narrowing, expiratory, 19 
Nematodes, 98 
Nerves, cranial, 127 
" dorsal, 131 
" spinal, 129 
Nervi thoracic! anteriores, 129 
Nervous system, most important 
clinical points in the anatomy 
of the, 124 
Nervus abducens, 128 
" accessorius, 128 
" acusticus, 12S 
" axillary, 129 

cutaneus medialis, 129 
" medius, 129 



i8o 



CLINICAL DIAGNOSIS. 



Nervus dorsalis scapulae, 129 
'- facialis, 128 
" glossopharyngeus, 128 
" hypoglossus, 128 
" ischiadicus, 13 1 
" medianus, 129 
" musculocutaneus, 129 
" oculomotorius, 127 
" olfactorius, 127 
" opticus, 127 
" radialis, 130 
" subscapularis, 129 
" suprascapularis, 129 
" thoracicus longus, 129 
" trigeminus, 128 
" trochlearis, 128 
" ulnaris, 130 
" vagus, 128 

Neumann, 65 

Neuralgia, 108 

Nothnagel, 64 

Nystagmus, 113 

(Esophagus, 56 

auscultation of, 56 
" length of, 56 

Ohm's law, 116 
Organs, digestive and abdominal, 

" genito-urinary, 67 
Oidium albicans, 102 
Otto, 5 

Ovarian cyst, 94 
Oxyuris vermicularis, 98 

Paresthesia, 108 

Paradox contraction, 123 

Paralysis, in 

" central, 126 
" functional, 1 12 

" peripheral, 126 

Paraplegia, III, 126 

Parasites, 96 

" animal, 96 

" in sputum, 36 
" vegetable, 101 

Paresis, 11 1 

Pectoriloquy, 30 

Pediculus capitis, 101 



Pediculus pubis, 101 

" vestimenti, 101 
Peptones, 79 

test for, 79 

Percussion note, Biermer's 

change of, 

26 

height and 

depth of, 

25 
Percussion tone, Gerhardt's 
change of, 26 
" respiratory 
change of, 26 
Phenols, 73 
Playfair, 137 
Plexus brachialis, 129 

" cervicalis, 129 

" lumbalis, 131 

" sacralis, 131 
Pneumonia crouposa, 15 
Pneumonococcus in sputum, 36 

staining of, 107 
Poikilocytes, 2 
Pole, active, 113 

" different, 113 

" indifferent, 113 

" non-active, 113 
Potassium, 76 

sulpho-cyanide of, 73 
Propeptone, 78 
Protozoa, 101 
Pseudoleucsemia, 6 
Pulex irritans, 101 
Pulse, 50 

" capillary, 43 

" dicrotic, 53 

" frequency of, 50 

" fulness of, 51 

" hardness of, 52 

" hyperdicrotic, 53 

" monocrotic, 53 

" quickness, 51 

" rhythm of, 50 

" size of, 51 

" subdicrotic, 53 

" venous, 43, 53, 54 
Rales, 28 

l< crepitant, 29 



INDEX. 



iSr 



Rales 



React 



, dry, 29 

metallic, 29 

metallic tinkling, 29 

moist, 29 

mucous, 29 

non-metallic, 29 

sub-crepitant, 29 
ion of degeneration, 120 

" complete, 



" " " partial, 120 

Red blood corpuscles, increase in 

" number of, 7 

nucleated, 3 

' ' number of, 5 

size of, 1 
" in sputum, 35 
" " urine, 89 
Reflex of the abdominal, gluteal, 

and scapular regions, 122 
Reflex, cremaster, 122 

exaggerated tendon, 112 
extinguished, 123 
"" increased, 123 
" patellar, 122 

pupil, j 23 
" sexual, 123 
" skin, 121 

of the sole of the foot, 122 
of the tendo Achillis, 122 
Reflexes, tendon, 122 
Relapsing fever, 13 
Renk, 141 

Respiration, Cheyne-Stokes, 20 
" jerking, 27 

" metamorphosing, 

27, 28 
normal relation be- 
tween the fre- 
quency of pulse 
and, 18 
number of, 18 
organs of, 16 
puerile, 27 
retarding of, 20 
' ' systolic vesicular, 2 7 

Reuss, 92 

Rhabdonema strongyloides, 99 
Romberg, ill 



Romberg, symptom of, in 
Round worms, 98 
Rubner, 139, 141 

Saliva, 56 

" constituents of, 56 

" diastatic ferment of, 56 

" reaction of, 56 

" specific gravity of, 56 
Sarcina in sputum, 36 
Scapula, 16 
Scarlatina, 10 
Scarlet-fever, 10 
Schizomycetes, 102 
Sense, of force, no 

of locality, 108, 109 
muscular, 109 
of position, in 
of pressure, 109 
of temperature, no 
Sensibility, 108 

" electro-cutaneous, IIO 
" to pain, no 
Sensitiveness of the deep parts, 

no 
Small-pox, 11 
Space, interscapular, 17 
Spasm, 112 

" clonic, 112 

" tonic, 112 
Sodium, 76 
Sound, clear, 21 

" cracked-pot, 21, 23 

" deep, 21 

" dull, 21 

" empty, 21 

" full, 21 

" high, 21 

" metallic, 21, 25 

" non-tympanitic, 21 

" tympanitic, 21, 24 
Spirillum, 103 
Spirometry, 20 
Spleen, 61 

" position of, 61 
Sputum, 32 

" actinomycosis in, 36 

alveolar epithelium in, 
34 



182 



CLINICAL DIAGNOSIS. 



Sputum, amount of, 34 

" animal parasites in, 36 
" aspergillus threads in, 

36 
" bacilli anthracis in, 36 
" black, 34 
" bloody, 32 
" blue-colored, 33 
" bronchial casts in, 35 
" cholesterine crystals in, 

36 
" Charcot-Leyden crys- 
tals in, 36 
" color of, 33 
" consistency of, 33 
" Curschmann's spirals in 

35 
" cylindrical epithelium 

in, 34 
" elastic fibres in, 35 
" fatty acid crystals in, 35 
" green, 33 
" hsematoidin in, 35 
' ' leptothrix threads in, 36 
" leucine crystals in, 36 
" leucocytes in, 34 
" lung parenchyma, 35 
" micro-organisms in, 36 
" morphological constitu- 
ents of, 34 
" muco-purulent, 32 
" mucous, 32 
' ' pavement epithelium 

in, 34 
" pneumonococcus in, 36 
" purulent, 32 
" " constituents 

of, 32 
*' purulo-mucous, 32 
" reaction of, 34 

red, 34 
" red-blood corpuscles in, 

35 

" sanguineo-mucous, 32 

" sanguineo-serous, 32 

*' sarcinse in, 36 

" serous, 32 

" smell of, 33 

" tubercle bacilli in, 36 



Sputum, tyrosine crystals in, 36 
" yellow ochre, 33, 34 

Stadium decrementi, 9 
" incrementi, 9 

Stage of incubation, 9 
" prodromal, 9 

Sternum, 16 

Stokes, 20 

Stomach, 57 

" digesting strength of, 

" examination of the 

contents of, 58 
" percussion of, 57 
" position of, 57 
" size of, 57 
" tumors of, 58 
Substances, non-nitrogenous, 138 
Succussio Hippocratis, 30 
Sugar of milk, 85 
Sulphuretted hydrogen, 87 

" " test for, 87 

System, circulatory, 41 
" nervous, 108 
" urine-producing, 67 

Table, dose, 144 
Taenia cucumerina, 97 
" echinococcus, 97 
" flavopunctata, 97 
" nana, 97 
" saginata s. mediocanel- 

lata, 97 
" solium, 96 
Tape-worm, 96 
Teeth, 55 

" milk, 55 
" permanent, 55 
Teichmann's crystals, I 
Temperature, 8 

of collapse, 8 
sub-febrile, 8 
Tension, diminished, in 

" increased, III 
Test for acetone, 85 
" " albumen, acetic acid, 
and ferrocya- 
nide of potas- 
sium test, 78 



Test 



INDEX. 183 


for albumen, biuret test, 78 


Test for santonine, 89 


" " heat test, 77 


" " senna, 89 


" " Heller's test, 


" " sulphuretted hydrogen, 


77 


87 


" " picric-acid 


" " tannin, 89 


test, 78 


" " thallin, 89 


" ammonia, 132 


" " turpentine, 89 


" antipyrin, S9 


" " uric acid, 132 


" arsenic, 88 


" " xanthine, 133 


" bile, Gmelin's test, 80 


Testing the sensibility, 112 


" " Pettenkoffer's test, 


Tetanus, 112 


81 


Thoma, 5 


" blood, guaiac test, 80 


Thorax, breadth of, 17 


Heller's test, 80 


" height of, 17 


" bromine, 87 


" narrow, 18 


" carbolic acid, 88 


" percussion of, 21 


" cystine, 133 


" size of, 17 


" diacetic acid, 86 


Thrush fungus, 102 


11 drugs, 87 


Touch sense, 108 


" grape sugar, bismuth 


Transudations and exudations, 92 


test, 84 


Transudations and exudations, 


" grape sugar, Bottger's 


albumen in, 92 


test, 84 


Transudations and exudations, 


" grape sugar, Fehling's 


contents of, 93 


test, 83 


Transudations and exudations, 


" grape sugar, fermenta- 


specific gravity of, 92 


tion test, 81 


Traube, half-moon shaped space 


" grape sugar, Moore's 


of, 57 


test, 82 


Trematodes, 100 


" grape sugar, Mulder's 


Tremors, 112 


test, 84 


Trichina spiralis, 99 


" grape sugar, phenylhy- 


Tricocephalus dispar, 98 


drazin test for, 84 


Trichomonas intestinalis, 101 


" grape sugar, polariza- 


vaginalis, 101 


tion test for, 85 


Triple phosphates, 76 


" grape sugar, reduction 


Trychophyton tonsurans, 101 


tests for, 82 


Typhus abdominalis, 1 2 


" grape sugar, Trommer's 


" exanthematicus, 13 


test, 82 


Typhoid fever, 12 


" iodine, 87 


Typhus fever, 13 


" kairin, 89 


Tyrosine, 87 


" lead, 88 


Tuberclebacilli, Ehrlich'smethod 


" lithium, 88 


of staining, 105 


" melanine, 87 


" in sputum, 36 


" murexide, 132 


" " inWeigert- 


" nitric acid, 88 


Koch's fluid for staining, 106 


" quinine, 88 




" rhubarb, 89 


Urea, 70 


" salicylic acid, 89 


" test for, 70 



1 84 



CLINICAL DIAGNOSIS. 



Uric acid, test for, 132 
Urine, 67 

" acetone in, 85 

" albumen in, 77 

" amido-caproic acid in, 87 

' ' amido - hydroparacumaric 

acid in, 87 
" ammonia in, 76 
" amount of, 68 
" animal parasites in, 91 
" antipyrin in, 89 
" arsenic in, 88 
bile in, 80, 81 
" blood in, 79 

" " guaiac test for, 
80 
" blood in, Heller's test 

for, 80 
" blood in, microscopical 

test for, 80 
" bromine in, 87 
" calcium in, 76 
" carbolic acid in, 88 
" carbonic acid in, 75 
" casts in, 90 
" chrysophanic acid in, 89 
" cystine in, 87 
" dextrose in, 81 
" diacetic acid in, 86 
" drugs in, 87 
" epithelium in, 89, 90 

fat in, 87 
" grape sugar in, 81 
" gypsum in, 76 
" nemialbumose in, 78 
" hydrochloric acid in, 74 
" inorganic constituents of, 

74 

inosite in, 85 
" iodine in, 87 
" iron in, 77 
" kairin in, 89 
" lactose in, 85 

lead in, 88 
" leucocytes in, 89 
" lithium in, 88 
" magnesium in, 76 
" melanine in, 87 
" mercury in, 88 



Urine, micro-organisms in, 91 

" nitric acid in, 88 

" normal constituents of , 70 

" organic sediment in, 89 

" pathological constituents 

of, 77 

" peptones in, 79 

" phosphoric acid in, 75 

" potassium in, 76 

" propeptone in, 78 

" quinine in, 88 

" reaction of, 68 

" red blood corpuscles in, 83 

" rhubarb in, 89 

" salicylic acid in, 89 

" santonin in, 89 

" senna in, 89 

" sodium in, 76 

" specific gravity of, 68 

" sugar of milk in, 85 

' ' sulphuretted hydrogen in, 

87 
" sulphuric acid in, 75 
" tannin in, 89 
" thallin in, 89 
_" turpentine in, 89 
" tyrosine in, 87 
Urobilin, 80 

Valves, aortic, 45 

" mitral, 45 

" pulmonary, 45 

" tricuspid, 45 
Varicella, 12 
Variola, II 
Varioloid, II 
Variolois, II 
Vertebral column, 16 
Vibrio, or curved rod, 102 
Vocal cords, closure of the, 38 

" " paralysis of the, 39 

" " tension of the, 38 

" " widening of the, 38 
Voice, 37 

" auscultation of, 29 

" bass, 37 

" closed nasal, 37 

" diphthonic, 37 

" falsetto, 37 



INDEX. 185 


Voice, hoarse, 37 


Weigert, 106 


" metallic, 30 


Welker, 5 


" open nasal, 37 


Westphal, 123 


" tripartite, 37 


White blood corpuscles, 3 


" want of, 37 


" large mono- 


" weak, 37 


nuclear, 3 


v. Voit, 137, 140, 141 


" large poly- 


Vomitus, blood in, 59 


nuclear, 3 


" carbonate of ammonia 


" number of, 5 


in, 60 


Wintrich, 26 


" epithelium in, 60 


Worms, flat, 100 


" gall in, 60 


" round, 98 


" leucocytes in, 60 


" small thread, 98 


" mucus in, 59 


" tape, 96 


*' oidium albicans, 60 


" whip, 98 


" remains of food in, 60 


Wunderlich, 8 


" sarcinse in, 60 




" schizomycetes in, 60 


Xanthine, 73 


" swallowed saliva in, 


" test for, 133 


59 




" urea in, 60 


Yeast fungi, 102 


" yeast cells in, 60 




Voussure, 42 


Zeiss, g 



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The quaint and sarcastic remarks strike the reader at once and cannot fail to enable him 
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HOW WE TREAT WOUNDS TO-DAY. 



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The laconic style of the author and the sledge-hammer way in which he deals with 
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